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62.72-1-34
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03112
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION Mn CONSTRUCT A WATER WELL
PCHD PERMIT d
WELL WELL LOCATION
Street Address
?
T x Grid Number
�VIW4? ,
WELL OWNER
e 1 i
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Address '/
�� ��02�/ G( / /�% �e
Private
D Public
SE OF WELL
primary
2'- secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL t3INSTITUTIONAL O STAND -BY
ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
19 REPLACE EXISTING SUPPLY
0 NEW. SjJPPLY NEW DWELLING
PEOPLE SERVED A /EST. OF DAILY USAGE aOO gal
O TEST/ OBSERVATION 1 ADDITIONAL SUPPLY
a DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED DRIVEN
®DUG ®GRAVEL.
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Q
Lot No.
WATER WELL CONTRACTOR: N
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __4NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ._,...._
LOCAT ON SKETCH & SOURCES OF CONTAMINATION PR,
/ ❑ ON SEPARATE SHEET
( e
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
thirt�� (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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 dri ng operations be contained on this
property and in suc a manner as not to /degrade or o r ise contaminate - surface or groundwater.
Date of Issue: 19 "d
-1 kw &4�2
of Expiration � 19� Permit Issuing Official
Date p 2
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110. Old Route Six . _ Center, Carmel, New York 10512
(914) 225 -0310
April 14, 1992
Firs. i4arcell,P,-�hmittman
utnam Valley, MY 10579
Re: Proposed Well Permit:
Schmittman
(T) Putnam Valley
TH 062,72 -1 -34
Dear Firs. Schmittman:
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Review of plans and other supporting documents submitted at this time rely *tive to
the above - captioned project has been completed. Comments are offered as follows:
1. Existing water supply has not been noted.
2. A sketch is to be submitted showing the location of the existing mater
supply, proposed well location and any septic systems within 200 feet of the
proposed well location.
.
Upon Receip� o$. -a -siammissiora, Tevlaeu 'i i; ''a "eflccf the Mha e . cvv!!'Orts. this
application will be considered further.
Very truly yours,
Robert Norris
Assistant Public Health Engineer
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RTIFIED TO:
FOAMS A'lJTCNl.STf t SIY /.VGS BANK
IfCUR14y T174L 4"AAN7L6 40 -VW
76rP ! 715706
JRVEYED: JULY 16,. /Y196
BOUGHT TO DATE
IOUGHT TO DATE
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Certifications hereon are valid for Bank.
Title Co. 8 Owners for this transaction
only Certifications are not transferable to x
subsequent Bank, Title Co. or Owners. �l j
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All certifications hereon are -Ad for this 1
t i4
and co FSHN SLV ATORE ROMEO
map copies thereof only if said map of
Cnuufsmi; Ertgm r � £.Ind Sn—yor
copies boar the impressed seal of the wr• ii ;
reyor whose signature appears hereon. 1 NORTHRIDGE ROAD
!� PEEKSKILL. N. Y.
"It is hereby certified that this surrey was
Prepared in accordance with the existing
Code of Practice fnr Lard Surreys adopted
t:. iE. & L. S. NYS LIC. NO. 027846
by the New York State Association of Pro-
fessionel Lend $urveyon, ENCRfALMENTS BELOW GRACE IF ANY NOT SHOWN
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/77, 178 ANO /79 Af J110,WA1 ON .•LIDO /6*8
fA7 144£0 1 101LVf/f0 .WP M 9 of ALlL!
PARk 09C4lVANA LA tf S/ /O ALIP B6/NG
/%LLO /N 7W 00;514C 4041AO4Y G44Rk1
PC/4NAM cowry, GARA/EL /V. Y.
A40- ZAIeIA /Y, /Vls.
SURVEY OF PROPERTY
FOR
MsIiPCfLLA SCh�/'� /TTM,4�li
SITUATE IN THE
row Of ~114,/ !/ALLFy
PUrwoAS COUNTY
NEW YORK
SCALE: I"= /0'
SURVEYED AS IN POSSESSION
(,*6 -,93-22,)
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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
April 14, 1992
Mrs. Marcell chmittman
,0, rte,, 2.q1
Putnam Valley, NY 10579
Re: Proposed Well Permit:
Schmittman
(T) Putnam Valley
TM #162.72 -1 -34
Dear Mrs. Schmittman:
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Reviev of plans and other supporting documents submitted at this time relative to
the above- captioned project has been completed. Comments are offered as follows:
1. Existing water supply has not been noted.
2. A sketch is to be submitted showing the location of the existing water
supply, proposed well location and any septic systems within 200 feet of the
proposed well location.
► TlarP =a -
:.... �.:.�•. _ �.`.:•._. .�.+#+.Ct:,.:;__...,.�..,:..;�� ,,x� a_ suiiin "i,�s�c,�;:.. bt�d'atp, sr,efect-.:t)se ab_ ova .comrent::,�...this�w�: ;.. ,. • � .._ �- <, _:
application will be considered further. � V
Very truly yours,
�, P A9
Robert Morris
Assistant Public Health Engineer
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