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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
',APPLICATION.. TO CQNSTRUCT..R„
PCHD PERMIT
WELL LOCATION
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City
Tax Grid Number a ,_s-
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WELL OWNER
M 11in Address
rivate
Public
USE OF WELL
1 - primary
2 - secondary
, IDENTIAL
O_BUSINESS
O:INDUSTRIAL
O PUBLIC SUPPLY
O FARM
[3 INSTITUTIONAL
O AIR /COND /HEA PUMP O ABANDONED
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
S`" gpm /# PEOPLE SERVED /EST. OF DAILY USAGE —r0'0 al
REASON FOR
DRILLING
PLACE EXISTING SUPPLY ❑ TEST /OBSERVATION LZ ADDITIONAL SUPPLY
SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
EIDUG
OGRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES . ` NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
.... `______ . Lot No.
WATER WELL CONTRACTOR: Name,Z , Z& c, Address:/
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER .MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET �)
d te) (signature)
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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 drill' g operations be contained on this
property and in such a manner as not to degrade or of rw/'be cont a ate surface or groundwater.
Date of Issue: 19 4_3
Date of Expiration /i 19 At- 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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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Norman Anderson Inc.
152 Barger Street
Putnam Valley NY 10579
JOHN KARELL Jr.. P.E. M.S.
Public Health Director
:... _:
December 10, 1993
RE: Proposed Well Permit
Hoetzel
(T) Putnam Valley
Dear Mrs. Anderson:
Review of plans and other supporting documents submitted at this time relative to
the above - captioned project has been completed. Comments are offered as follows:
1. Location of the existing water supply has not been noted on plan.
2; The preposed well - l.ocationlis_ -_ with -in 100, _feet-- of. separation :between :a
well and septic system.
Upon receipt of a submission revised to reflect the above comments, this
application will be considered further.
Very truly yours,
Robert Morris
Assistant Public Health Engineer
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