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03436
-C G DEPARTMENT OF HEALTH
Division'of Environmental Health Services
* 10 OLD ROUTE SIX CENTER;. CARMEL, N.Y. 10512 (914) 225 - 0310;';.;,;;. .
PCHD PERMIT #W-J69-
WELL LOCATION
Street A $ dress
r� �� / #
To Village Ci y Tax'Grid
<7 _ ��� ll�
. Number
WELL OWNER
Name Mailing Address
S Cl; vn L-
JgPrivate
O Public
USE OF WELL
1 - primary
2- secondary'
%RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑PUBLIC SUPPLY QAIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
C1 ABANDONED
O OTHER (specify
13
AMOUNT OF USE
.YIELD SOUGHT
gpm /# PEOPLE SERVED / EST. OF DAILY USAGE gal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY ❑ 'TEST /OBSERVATION GE ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING EEPEN EXISTING WELL
DETAILED,
REASON FOR
DRILLING
Goers
WELL TYPE
MDRILLED
DRIVEN
QDUG
GRAVEL
D
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES No
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
X11 Q Lot No.
WATER WELL CONTRACTOR: Name (2n
.Address,:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
It
INAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY I
DISTANCE:.T�PR iPEItTY- :FROM- NRAREST.. WADER.MAIN. -. - - - _
... . ti P w yao.•- RTY -,. +..w_.we.w.. -. w ..q �++v^•• - -.,.. •-.. _.. �►1 w Vi+.- .mow. - + +•— �e'�^w_Mw.Y`«. ._ _ _.1 .._.•.......s•. _ —,w
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
(� ON SEPARATE SHEET
(dat) (signature)
Ww'130
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
Health Department.
Date of Issue: A 19
Date of Expiration: 19
Permit is Non - Transferrable
Rev. 10/88
Report on a form provided by the Putnam County
("
96 Permit Is-suing OffWaT
White copy: H. D. File f --
Yellow copy: Building Inspctor`
Pink Copy: Owner
Orange copy: Well Driller
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i 1.
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J^` 3ac.,.s ; `°'.,�"' , ' ,r '.S. ,. -r.+?, _ d .l.S' k""'a 'rF'... :• G s�r...e_3'y" �.,�?.?Y y -.
MARVIN O'DELL
TOWN HALL
PUTNAM- �V�A�LLEY, N.Y.
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
December 13, 1988
�.� Department of Environmental Health
-,110 Old Route 6
Carmel, N.Y. 10512
Re: Proposed Well
TM #74 -4 -29
Gentlemen:
The proposed Water Well site as shown on the attached
drawing was inspected on 12/9/88 , and as could
be determined was found to be a minimum of one
hundred (100') feet from any reported sub - surface
sewage disposal area.
R6asons for drilling - .Existing well dry.
Applicants that receive permits shall -upon completion
of construction, submit to the Town of Putnam Valley
(Building Department)a.copy of the well drillers Log
and Water analysis report before said well is put_
in service.
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r
MARVIN 0 D
Building Inspector
MO' D : e s