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PUTNAM COUNTY DEPARTMENT OF HEALTH _ - -- ` ;`
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
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please print or type GIiDPefmit
Well Location
Street Address: Town/Village: Tax Map #
ae> �rti ' J Tot
is V �d �N Maw Block (s)
Well Owner:
Name:
Address ,
Phone #:
Use of Well:
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 gpm # People Served Est. of Daily usage " °` gal.
Replace Existing Supply Test/Observation —Additional, "Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Tye
Zbrilled Driven 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: =a-c-vo k Address:
Is Public Water Supply available on site? ....................................... ............................... Yes _
Name of Public Water Supply: Town/Village
Distance,to property from nearest water main:
Proposed'well location & sources of contamination to be provided on separate sheet/plan.
De.te:._ �.:r_ tl A licant Si nature: Gt t�lyiz
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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 County Health Departmel
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 alt ation of the appr ed plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam C u ty.
Date of Issue 3:�4 Permit Iss J Offic
Date of Expiration � ,r Ln Title:
Permit is Non - Transferable
White copy - HD .file; Yellow copy - Building Inspector; Pink copy - O er; Orange copy - Well driller
4/ Form WP -97
Rev. 3106
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
July 11, 2008
Dear Mr. Anderson:
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
Re: Proposed Well Woermann
230 Wood Street
(T) Carmel
A field inspection was conducted on the above referenced lot by Mitchell Lee, Public
Health Technician. The application to drill a new well is approved with the following
stipulation:
1. A. �'I1ell Completion Report (WC -97) shall be. submitted no later than 30 clays. after
the, wells' completion by the permittee.
Please contact me at (845) 225 -5186 ext.2233 if you have any questions.
Sincerely,
Mitchell D. Lee
Public. Health Technician
Environmental Health (845) 278 -6130 Fax(845)278-7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
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--DWE
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