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BOX 25
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71 S LAW A
02995
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION oQ ^I
OWNER'S NAME I-a
MAILING ADDRESS d!
n OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
` ame a atlons Ip (i.e., owner, tenant, etc.
DATE
PROPO
ADDRESS
TYPE FACILITY
INSTALLER_ /�a�G� -� �or� ,�� - PHONE
REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
a� owner,-or:- reporwd. agent of oymer -a Pe to Ile- conditions stated:on this--forrn:
SIGNATURE �i_� i TITT,E
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
DATE 6
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
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A
®G DEPARTMENT OF HEALTH
+ '1% Division of Environmental Health Services
.� 4 Geneva Road, Brewster, New-York 10509
* (914) 278 -6130
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PCHD PERMIT #
WELL LOCATION
Street Address
ALF 54-
To Village it}�, Tax Grid Number
T
arvie�
,. v�- M Ul l� 17-3—
03
WELL OWNER
Nam
9LQ
Mailing' Address 3as F 5-9" S1-.
91Private
0 Veto 0 a aa-
O Public
USE OF WELL
SMSI.DENTIAL.
® PUBLIC SUPPLY ®AIR /COND /HEAT PUMP
®ABANDONED.
1 - primary
0 BUSINESS
0 FARM 0 TEST /OBSERVATION
0 OTHER (specify
2 - secondary
® INDUSTRIAL
O INSTITUTIONAL 0 STAND -BY
AMOUNT OF USE
YIELD SOUGHT S gpm /# PEOPLE SERVED S- /EST. OF DAILY USAGE 500 gal
) REPLACE= EXISTING- S�UPP -LY 0 TEST /OBSERVATION ADDITIONAL SUPPLY
REASON FOR
DRILLING
0 NEW SUPPLY NEW
DWELLING ® DEEPEN EXISTING WELL
DETAILED
REASON FOR
L C tktu 0 e-14
DRILLING
_
WELL TYPE
L3DRILLED
®DRIVEN
®DUG
®GRAVEL.
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES V NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
. Name
to 0
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 'NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY -FROM NEA'RES tWA-'i
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
1�
�ON SEPARATE SHEET
G �G � ,
Oate (si ature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department'attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilli operations be contained on this
property and in such manner as not to degrade or othe is contaminate surface or groundwater.
Date of Issue: 11irl 19 13
Date of Expiration l 19 Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
6
Boyd Artesian Well Co., Inc.
Carmel, N.Y. 10512
- (914) 225 -3196
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