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03499
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03499
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
({91.4�r)']!�y2}�7r /8- �6y�130 �yy� •���•
:1, >.' :.ti. � .:: L'1iPLiC.'!'!1 �11Y-- 1',1:7' �iVLY►71 SCV ".' A1Tr '�' .+.L' L- .':;.".•:.
PCHD{ PERMIT $ a
WELL LOCATION �,�
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
h re e. Arrows Lot No. 'SZ.
WATER WELL CONTRACTOR: Name
Address: /A .y
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ ZL NO V"��y4
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
Ia- STANPE= TO. PROPERTY _- FROM. -NE-A E-ST WATER °MAIN: - - -:._ _ _ , . _.;a.„....,__ .• a...._, _,.. _ : <- ..., -�
LOCATION SKETC & SOURCES OF CONTAMINATION PROVIDED
GON SEPARATE SHEET
(date) //////���� (signature)
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
thirt3' (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 manner as not to degrade or othe i e contami ate, surface or groundwater.
Date of Issue: 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
Street Addree -ss
Town/Village/City � Tax Grid Number
WELL OWNER
Name
G
Mailin Address Private
/ a O ublic
USE OF - WELL
1.- primary
2- secondary
RESIDENTIAL
BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEA PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED `— /EST. OF DAILY USAGE fo d,gal
D PPLACE EXISTING SUPPLY , ❑ TEST/ OBSERVATION. 13. ADDITIONAL SUPPLY
JXNEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
RILLED
DRIVEN ODUG �6RAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
h re e. Arrows Lot No. 'SZ.
WATER WELL CONTRACTOR: Name
Address: /A .y
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ ZL NO V"��y4
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
Ia- STANPE= TO. PROPERTY _- FROM. -NE-A E-ST WATER °MAIN: - - -:._ _ _ , . _.;a.„....,__ .• a...._, _,.. _ : <- ..., -�
LOCATION SKETC & SOURCES OF CONTAMINATION PROVIDED
GON SEPARATE SHEET
(date) //////���� (signature)
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
thirt3' (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 manner as not to degrade or othe i e contami ate, surface or groundwater.
Date of Issue: 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
MARVIN O'DELL
Bldg. Inspector
JOHN MAHONEY
Deputy Zoning Inspector TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
To Whom It May Concern:
June 6, 1994
PUTNAM VALLEY, N.Y.
(914) 526 2377 1
BETTE STOCKINGER
Bldg. Dept. Clerk
Re: Costello - 116 Rochdale Rd.
Camp Three Arrows
Proposed Water WEll
The above noted proposal was reviewed and found
to be in compliance with attached site of house
#116, "Camp Three Arrows".
0
Building & Zoning Inspector
enc. Site Plan
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