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03140
DEPARTMENT OF HEALTH
Division of Environmental Health Services
_'110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
�APPLICATON,TO- CONSTRUCT- A, WATER �WELL
PCHD PERMIT#
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
Wood Putnam Valle
WELL OWNER
Name
Tom Kuck 645
Mailing Address OPrivate
Rte 6N Maho ac NY D Public
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION 0 OTHER (specify,
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE Sal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13. ADDITIONAL SUPPLY
0 NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
Shares well
with neiahbor
Date of
Expiration 19
Permit Issuing Official
Permit
is Non - Transferrable
White
WELL TYPE
3/89
®DRILLED
Yellow
DRIVEN DDUG ®GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name P. F. Beal & Song , Inc. Address: 4 PutnamAve . , Brewster , NS
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
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LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
MON SEPARATE SHEET
7/27/92 r
(date) (sigr
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
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
drilling operations be contained on this
property
and in such a manner as not to
degrade or
otherwise contaminate surface or groundwater.
Date of
I s sue :.��//�Y �� 19
Date of
Expiration 19
Permit Issuing Official
Permit
is Non - Transferrable
White
copy: HD File Pink-copy: Owner
3/89
Yellow
copy: Bldg: Insp. Orange copy: Well Driller
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1111 LY['fl•I��LV•i't:,•laut�.'Ji'll 17lJrL"!i \n'iL'1Vi .�•. - •�'J•�. ^'��.� � // /�
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Joan M. Simmons, M.D.
Deputy Ccmmi.ssioner of Health - FIELD ACTIVITY REPORT -
NAME / 4::�' /-X-7 /"f Ce,
ADDRESS (2� S
IM No.
MAILING ADDRESS
P.O. Box Post Office Zip Code
DI W "ei-IN
PERSON IN CHARGE
OR INTERVIEWED _
Name and Title
DATE J 9E FACILITY _..
TIME ARRIVED
FINDINGS:
TIME LEFT
Sheet ' of
Orig. Routine
Orig. Complain
Orig. Request
Compliance
Complaint Canp
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
..o —,".-
Signature and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
M.
TITLE: