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BOX 27
03345
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
lrlw fidN `20 CUN8TRUCT ''WATeR WkLL__ ......_.. � _ _ _.......z..rt .. .
PCHD PERMIT-#U)1 6 '
WELL LOCATION
Street 'Address
/ 17 LvDleo u 7 s r
Town/Village/City Tax Grid Number
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WELL OWNER
�Name' Mailing
v , 6444Se Y oZ v o 7-
Address rivate
f f ` A. i + &41 LCt �l ltylor7f O Public
USE OF WELL
1 primary
2- secondary
11 IF
l ' O'RfESIDENTIAL O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP O.ABANDONED
0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
O INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT /o gpm /#
.PEOPLE SERVED /EST. OF DAILY USAGE 2av gal
REASON FOR
DRILLING
U REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING)
D TEST /OBSERVATION 13- ADDITIONAL SUPPLY
9 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
Ec.L ,fit AJS AO&Y -
No "147 -6Z .0,v A 4?r3 1cV )3,1)-XIX
WELL TYPE
ILLED
CIDRIVE14
11DUG
aGRAVEi<
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES l,,10"NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No..
WATER WELL CONTRACTOR: Name A101CMp1✓ Avoe;1,fO / -Address: 174e %
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
LkR'9ST .WAT1QRl i ,I : _ _.. . !✓'� i.: � `� r�.'i� _.. .. ._. _L
LOCATION SKETCH& SOURCES OF CONTAMINATION PROVIDED
fON SEPARATE SHEET
ate (sig ure)
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 of ise contaminate surface.or groundwater.
Date of Issue: �� 19 q0 ( t L,--� /
f zo
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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maw s NAME 17; r° 9— %' �.� �� C'� 5'c v PHONE
SITE LOCATION ii# 7f
MAILING ADDRESS ?7u i N 9m 1 & Z t e Y
PERSON INTERVIEWED �i'�i L S Pam Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY 3 POP,
� O P,
PROPOSED INSTALLER PHONE 7 32- 2-8
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair mus be in same location and of same type as original sewage disposal system.
Different locati(� may require submittal of proposal from licensed professional engineer or
registered architect.
W I - C A PAc-10 1 14 F11•- 'R,-7'67 R S sir 1,A4
AN 0 Oat & 5V51 -5A -
Proposal approved
Inspector's Signature &
rouosal aooroved with the following conditions:
Disapproved
1. Procurement of any Texan permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
fivl Jr,
VAFA��M ��
(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and oonditions.
I, as owner, or repoj,Jjy, �� agent of owner agree to the above conditions.
SIGNATURE ,I TITLE4��.,�„� DATE
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