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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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please print or type C fDe Wt7a +/ .y,
Well Location
Street Address: Town/Village: Tax Map #
St y �v y <1°'� Map Block Lot(s)
Well Owner:
Name:
Addres :
Phone #:
?�1'r � / �Z1-
aS S' �✓voc/ S'f , l%9c, �lo��c., /�
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Use of Well:
___�6i`esidential _Public Supply Air /cond /heat pump _Irrigation
1- Primary
Business Farm Test/monitoring _Other(specify)
2- Secondary
Industrial Institutional Standby
Amount of Use
Yield Sought z gpm # People Served Est. of Daily usage gal.
Replace Existing Supply Test/Observation 4—,Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
A/. S ti
for Drilling
Well Type
Drilled Dri en Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _ No
Is well located in a realty subdivision? ........................................... ............................... Yes _ No
Name of subdivision Lot No.
Water Well Contractor: Address•1s Si .
v aO . dh 1;,p -
Is Public Water Supply available on site? ..................................... ............................... Yes No`,-G-
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location 8 aources of contaminatiqn to Oe provided on separa e,sheet/plan.
Date: `'f- 17Z Applicant Signature.
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam Countv Health Departmei
take appropriate action to assure that any and all water and 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.
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified
when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam 4unty. A /r
Date of Issue _ .4,11-11 Permit I
Date -of Expiration I _ Title: —
Permit is Non-Transferable
White copy - HD. file; Yellow copy - Building Inspector; Pink copy - Owner;
I
copy - Well driller
Form WP -97
Rev. 3/06
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SBERLITA AMLER, MD, MS, FAAP
Commissioner of Health
ROBERT MORRIS, PE
Director of Environmental Health
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
PAUL ELDRIDGE
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Subject: Proposed Well Maiuzzo
225 Wood St.
(T) Putnam Valley
April 14, 2011
Dear Mr. Anderson:
A field inspection was conducted on the above referenced lot by Vincent Perrin, Public
Health Technician. The application to drill a new well is approved with the following
_ . s.tip;ilat:oj:. _^ _
1. A Well Completion Report (WC -97) shall be submitted no later than 30 days
after the well completion by the permittee.
Please contact me at (845) 808 -1390 ext.43131 if you have any questions.
Sincerely,
4cent Perrin
Public Health Technician
cc: file
Office (845) 808 -1390
Fax(845)278 -7921
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