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HomeMy WebLinkAbout3922DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.50 -1 -12 BOX 30 03922 jig I OJ6 I Ll 1� 16 r L Ir 'T. ' , All 03922 -' PETER' C. ALEXANDERS6jqF - -- - •- County Executive a Y DEPARTMENT OF HEALTH Division Of Environmental Health Services June 2, 1987 Mr. Harvey Blitzer 53 -45 194 Street Flushing, New York 11365 ..JOHN 'SIMMONS. M.D. .. Deputy Commissioner ' Re: Well Permit (Gross) Northway & Tanglewylde Rds. Lk. Peekskill, Putnam Valley, NY Dear Mr. Blitzer: As per our telephone conversation of this date and your application for Access to Public Records, enclosed please find copies of correspondence relative to the denial of this Well Permit. If you have any questions, please contact me at this office. JK: cj Encl . cc: file JK ;- Very truly�j yours, C"/ .. John Karell Jr., P.E. Director, Environmental Health Services 110 OLD ROUTE SIX CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION FOR PUBLIC ACCESS ;..j WND . if j et TO: RECORD ACCESS OFFICER PE TNA11 Mental He OUNTY 1 alth Sprvi PH L. PELOSO, JR., PU C Ivan,► ,�8 0 Bldg 3 Iv7nw`",ATION OFFICER ­__10512 Address„, I HEREBY APPLY TO INSPECT THE FOLLOt•7ING RECORD: � a .•_9•- -.2, . t V. Signature - Representing LIB i i Mailing Address FOR AGENCY USE ONLY x P?P ROVED - - .:° 2 L P�h a ,1 U Date r M..r FL: � M DENIED Record of which this agency is Legal Custodian cannot be found. Record is not maintained by this Agency Signature Title Date NOTICE: YOU HAVE A RIG 1T TO APPE. ?L A DENIAL OF THIS APPLICATION TO THE PUTNAM COL��TY:'EXECUTIVE . Nana Business Address WHO MUST FULLY EXPLAIN HIS R?ASONS FOR SUCH DENT. IN WRITING SEVEN DAYS OF RF-CEIPT• OF PV APPEAL. I HEREBY APPEAL: ignature Date PETER C. ALEXANDERSON County Executive JOHN SIMMONS. M.D. Deputy Commissioner DEPARTMENT OF HEALTH JOHN KARELL, Jr., P.E. Director Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 April 27, 1987 (914) 225 -0310 Mr. Gil Porcelli 116 First Street Yonkers, New York 10704 j RE: Proposed Well Gross Northway & Tanglewylde Lake Peekskill Putnam Valley, N.Y. Dear Mr. Porcelli: Please be advised that a well permit for this property was previously rejected in a letter from the writer dated August 18, 1986, copy attached. The proposed well must be drilled at least 150 feet from the adjacent sewage disposal system which consist of leaching pits. It is suggested that you contact a local professional engineer for guidance in.this matter. A copy of our engineer's list is enclosed. If you have any questions, please contact the writer at Ext. 304. JK:pt cc:Building Inspector JK r t fly , John K-rell, Jr., P. E. Director, Environmental Health Services RUFFS 31%AL. FS aBMMERS RS Lum, THOMAS . 84 ROSEHILL AVENUE NNUNZIATA, FRANC �. TARRYmm, NY 10591 D #1, 20 KRYSTW DRIVE Tel: CMERS, NEW YORK 10589 Tel: 248 -7647 M, JOHN ALDWIN & CORNELIUS 120 BEDFORD ROAD ARMO6K' NY 10524 �RLA & cy-WE) D #6, MiLifE `l.2'' .. .. MORRIS & ANCROS RESTER, NY 10509 Tel: 279 -7115 367 VIOLET AVENUE OUTE 22 & HARDSCRA88LE ROAD p0LjanaZpSIE, NY 12600 ELLUSCIO, LAWRENCE f. Tel: 631 -8819 Tel: 769 -9195 LAND SURVEYORS Tel: 454 - 3411 BURGESS & BEHR RFD #8, HORSEPOND ROAD CARMEL. NEW YORK 10512 RKS BOL7LEVA4D PISARI, TONY Tiel: 962 -2689 OLD SPRING, NY 10516 Tel: 265 -9342 190 LmusT STRET Tel: 225 -1811 - DEVLNE, .JAMES , NEW YORK 10566 Pte OR ;Zggp ASSOCIATES Tel: 855 -9211 OUTE 22 & HARDSCRA88LE ROAD Ywn-ms, 'JOHN ROTON FALLS, NY 10519 ( KUNNY) Tel: 277 -5805 RD #9, FAIR STREET STANLEY 173 LEKINGTt7N AVNUE ' CREMES,, ' NY 10512 Tel: 878 -6170 ASHIN �:r .? . •::: _ _ Tel: 677 -8151 WTE 52�PLAZA ,;L:av: MINA, SAL-:, : '.:`'• ARMEL, NEW YORK 10512 Tel: 225 -8088 VALLEY POND ROAD 101TONAH, NY 10536 ': ==: Tel: 248 -5815 Rom, TI?X71HY :4 MAPLE PLACE " iSSDUM, NEZ9 YORK 10516 Tel: 941 -5421 IDGE ROAD :1 I RAD 4pE F-ca aL,' NY 10566 s'3 •.:.,. .: Tel: 737 -1056 ROM=, MURRAY Sx'C ^a �� 7.'r •: � 'ARK VIEW ROAD .c- _ ;FOA1N, ARTHCNY �`.' "': , a3ND RIDGE, NEW YORK 10576 Tel: %.`r•:`'i; 763 -5907 'OLD GLEMAM FdAD..:::,.`'.. -. . PO BBC 282 '_::.....• ,. WLY, MICHAEL T, .GLENiAM, NEW YORK 12527 Tel: 831 -3030 DX 243 HE OROCK, NEW YORK 10587 Tel: 628 -0507 SPECTOR, MARVSN 174 BRADY AVENUE I'AOUM, JOHN, V. " HAwnio E, NEW YORK 10531 Tel: 747 -1123 D #2, BOX 89 VINV4 VALLEY, NEW YORK 10579 Tel: 526 -2039 `' , pATTi MS70RMZCK UPPER STATION ROAD )ELAND, - -'1 GARRISON, NEW YORK 10524 Tel: 424 -3848 SADEY & WATSCN '' '265 '' MLD SPRING, NEW YORK 10517 Tel: 265-92i7 -9217 �.- mn= cEuv2N ASSOCZR2T5 XXVIM, "" :% = ;' ONE OVEROC K R ROAD ` -' '�: BOX 20Y0 -';:: - :•:;,.... .;: ^: - �.. .-,; { •j. PO(SIE, NY 12603 Tel: 454-3980' �tnED...v11, RE MDUIDGE ROAD ' . • i , :,:.: ^! - I' ?4 SULLIVAN, FRANK fAROPAC, NEW YORK 10541'..` -.Tel: 628 -7576 4:, 2972 FERNCREST DRIVE y�alokN HEIGHTS, NY 10598 Tel: 962 -4248 SMQ RFC DONALD .49 LLONGRELL ROAD E. SWANSON, JOHN WARCIMT MANOR, NY 10510 Tel: 941 -7911 RFD 34, GEYMER DRIVE :: MAEMpAc, NEW YORK 10541 Tel: 967 -5400 .VLCHFTTZ, J. ROBERT a ASSOC. .0 BOX 374 TAVIIJO, PETER '. 77 INo, Tt3N ROAD , WIER, FRANK IZTOcE, pO!&1�06897 ._:.. FILI Tel: 2203- 762 -5054 386 MAIN STREET 225-9024(h) UMGEFIELD, CONN. 06877 Tel: 203- 438 -0416 mmmom, ROY CUTE 6 & CHERRY LANE 4AHOPAC, NEW YORK 10541 MCKER, GERALD I SADORE LANE (ONKERS, NY 10705 LRISH,JAMES, PE 3 ALDAR COURT 2EEKSKILL, NY 10566 7 & E ASSOCIATES 3PZLS4AY ROAD SHRUB OAK, NY 10588 IACOBSEN, NATHAN, ASSOCIATES DENLAR DRIAVE PO BOX 337 CHESTER, CT. 06412 KEANE ASSOCIATES 113 SMITH AVENUE MOUNT KISOO, NY 10549 KEuARD & FEDERIC0 359 MAIN STREET MOUNT KISCO, NEW YORK 10549 LANDER, STANLEY PO BOX 'L' AMA7ALK, NEW YORK 10501 7AURE>'TT, RANDOLPH 212- 566- 3572(b) Tel: 628- 4392(H) Tel: 779 -7008 Tel: 528 -9338 Tel: 245 -6320 Tel: 203-526 -9591 Tel: 241 -2235 Tel: 241 =1414 Tel: 245 -2645 WILSON MILTON RR #2 BREWSTfR, NY 10509 ZEILER, WILLIAM CONCORD ROAD MAHOPAC, NEON YORK 10541 ZENZ, FRED 292 MAIN STREET NELSONVILLE, NY 10516 Tel: 225 -3312 BE RGE NWRFP, ROBERT 151 EAST MAIN STREET BREIISTER,NY 10509 Tel: 279 -4261 BUNNY ASSOCIATES .FIELDS LANE RR #2 NORTH SALEM, NY 10560 Tel: 277 -3404 BADEY & YATSON ROUTE 9 COIL) SPRING, NY 10516 Tel; 265 -9217 CARPENTER, HENRY 2070 SAW MILL RIVER ROAD YCFinawN H=GaTS, NY 10598 Tiel: 962 -2689 COHERFam, JOSEPH LARCHMONP ROAD CARMEL, NEW YORK 10512 Tel: 225 -1811 - DEVLNE, .JAMES • 4 MAPLE BOULEVARD 'PAWLING, NEW YORK 12564 Tel: 855 -9211 GDRR, RICHARD IiVIFW DRIVE MAHOPAC, NEW YORK 10541 Tel: 628 -8785 3OF�)S0N, `' STANLEY 173 LEKINGTt7N AVNUE ' MOUNT 10549 Tel; 241 -3872 ��KISCO,,�NpY CAMBY ROAD VERBANK, NEW YORK 12585 Tel: 677 -8151 SELLS, CHARLES 550 NORM BEDFORD ROAD BEDFORD HILLS, NY 10517 Tel: 241 -4944 WALa=' D: CHAUNCfY ROAD CAR'., NL *10512- "' Tel: 225 -7008 DUSHIN FRANK 907 SOUTH STREET PEEKSKILL, NY 10566 Tel: 737 -4713 GREENBERG, JOEL - RR 8, MUSOOOT NORTH BALDWIN PLACE ROAD MAHOPAC, NY 10541 Tel: 628 -661 Tel: 669 -5290 HOLT, JAMES ROUTE 116 PURDYS, NY 10578 Tel: 628 -4764 WEY' RICHARD ROUTE 22 BREYSTER, NY 10509 Tel: 265 -4018 Tel: 277 -418c Tel: 279 -561 DAVID D. BRUEN County Executive DEPARTMENT. OF HEALTH Division Of Environmental Health Services August 18, 1986 JOHN SIMMONS, M.D. Deputy Commissioner Mr. Samuel Gross Northway and Tanglewylde Lake Peekskill, NY 10537 Re: Proposed Well Construction Northway & Tanglewylde (T)Putnam.Valley TM 80 -2 -1, 2, 18, Appl. #W -7 -86 Dear Mr. Gross: Review of a revised sketch relative to the above application and field inspection of the parcel on August 14', 1986 by a re- presentative of this Department indicates as follows: 1. The adjacent sewage system, consisting of seepage pits or a cesspool and the sewage system serving your house, which is also a pit system are not 150 feet from the proposed well. 2. . T.he house is pre,se'ntly ­on ­supplied by the Lake Peekskill Water Works. Recognizing the above and that a minimum restrictive distance of 150 feet is required between a see.page.pit system and a well, your application for a permit to construct a well on this property is hereby DENIED. Eery tru y yours , 1 ; P hn Kar. 11, Jr., P.E. Director Environmental Health Services JK:amm cc: Mary O'Dell, P.U. Building Inspector JK File JSH TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ,µms,✓ ��„� �w 'N4 _.; 2 i j Torque FKoarg6E AREA 353 =-6" Bloc K 53 (CAKE PCLIKSKitL Af Y. i E' RrAR - � C'1 � o HsE z6' y g ' s �< �Ro/VT { fut=i r 6 C z''��. jji•� -- '� �' _.., R SEE D sb - -- -- - - -- - -- PR o P E y pR 7 'OF SCALE IV. : N. T. S. Q4dG, PRCPARED FOR: DWG NO: of 1 GIGO /�oRCNEL I i ' TA IV GL_ 'E wYLD� i� r wiafsT Po iN r \`il.�•k(X �v.�.re ��r4.h� u „. - ''^-- --'�--- --^� -. QtXite]o%.3�34 —ox Se 6 oo t R, c' rn '/ y RrAR - � C'1 � o HsE z6' y g ' s �< �Ro/VT { fut=i r 6 C z''��. jji•� -- '� �' _.., R SEE D sb - -- -- - - -- - -- PR o P E y pR 7 'OF SCALE IV. : N. T. S. Q4dG, PRCPARED FOR: DWG NO: of 1 GIGO /�oRCNEL I i DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 -APPLICATION ''t"G 'CONSTRUCT A WA'T'ER WELL:' PCHD PERMIT #11 -�� WELL LOCATION St eet Ad dre s SUPPLY: T Town Vila e C' yy� „y� TaX Grid Number WELL OWNER Nam L M,6111 it A.g- P'i d'J� Ad res -%v I OPrivate ❑ ub USE OF WELL 1 - primary - secondary RESIDENTIAL O BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM ❑ TEST /OBSERVATION O INSTITUTIONAL O STAND -BY ABANDON ❑ OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVE /EST. OF DAILY USAGE gal REASON FOR DRILLING MNEW SUPPLY OREPLACE EXISTING SUPPLY , ❑ PROVIDE ADDITIONAL SUPPLY ❑DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING �' M .r e: I 2 aN fN41.fit (°> r- WELL TYPE RI D D DRIVEN DUG O GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? "j YES V NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name . o i- 'i av, C x. �� tai' Address: T S IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF P PUBLIC WATER S SUPPLY: T TOWN /VIL /CITY °._ DISTANCE TO, PROPERTY F FROM - NEAREST LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION []ON 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 thirty (30) days ofthe'completion of water well construction, the applicant s.hall: 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. Date of Issue: 19 Date of Expiration: 19 Permit Issuing Official Permit is Non - Transferrable White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner 287 Orange copy: Well Driller ,.�9 es> - DAVID D. BRUEN County Executive - DEPARTMENT OF HEALTH Division Of Environmental Health Services 1T78- JOHN SIMMONS, M.D. Deputy Commissioner August 5, 1986 Samuel Gross Northway & Tanglewylde Lake Peekskill, New York 10537 RE: Proposed Well Construction Application # i-7 -86 Gross,Northway/Tanglewylde (T) L. Peekskill Dear Sir: -". E5G 2- (' Z) /6 Review of the above captioned application has been canpleted. Additional information or clarification is required as checked below: V 1. A detailed reason for drilling the well is required. A short narrative is required. For what purpose will the well be used, drinng; lawn � watering, etc. �� ���i.� -� � y�i� -ei,► \/ 2. Is the site presently served by a well? Explains. ,X Is the site presently served by a sewage disposal system? Explain �I4, Is the present structure to be reconstructed? JkpandecL? HGw ? . 5. A sketch showing the location of: -the -proposed well - the existing sewage system on this parcel - the existing house on this parcel - existing sewage systems and wells on adjacent parcels within 200 feet of the proposed well. - all of the above is not provided. 6. The sketch provided is not sufficiently detailed. See #5 above. Upon receipt of the above information this application will be considered further. te trul yours, r ohn Karell, Jr., P.E. JK:mk Director Environmental Health Services cc: Bldg. Insp. F/L /jk -3 TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 Ll I A. SK!, , "InINNAT rz MOVE I son I . 1. ....... rr sit tot ATIAX . . . . . . . . . . . . . . . . . , P2 Ll I A. SK!, .%,-t vc�'.* i` str "i�•`S2�<'+t"+�.'Si- '1�*"•o��.y��!_.•.',., 0k�w' r..�?+{++.t«?s�:'t`' SBA•.+'."' Y�%,5+"'SSb�'k.�'.t�;"a�fT's'e' "�'?*.:tr�T�e', .. •.r _2 .. _ ,� Yc.}+... L axw "4'A•: r.... .... .: 4. - i.. ... rr. - .. F .... .:.n ..�._ .. D PA NT .. HEALTH Division Of Environmental 1­14�alth Services • r TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225-3641 Q APPLICATION TO CONSTRUCT A WATER WELL WELL LOCATION —MEETAUORESS. y,0A TUUWN /V1LLAGE1C11Y IAX GRiO NUMBER. WELL OWNER NAME. • ADDRESS: i� rd �c- :.�,,<4 rr L�j- [ SIVATC ❑PUBLIC USE OF WELL WIEESIDENTIAL. ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary ❑ BUSINESS ❑ _FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 -secondary ❑ jNDUSTRIAL ❑ INSTITUTIONAL. ❑ STAND -BY ❑ (MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR 2`NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERV4.T!ON DRILLING ❑ gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL WELL TYPE DRILLED DRIVEN DUG E] GRAVEL 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 Address: ES PUBLIC WATER SUPPLY AVAILABLE TO SITE: Y YES NO - NAME OF PUBLIC -WATER . SUPPLY: L �.�� �J, / TOWN /V%C - - ?ISI'ANCE TO PROPEnTY -' -FROYr *NZERR€'ST—YTATER.MAIN . , OCATION SKETCH & SOURCES.-OF CONTAMINATION. (&ate). (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 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.. Date of Issue: .'19 ssuing - ....: f icial . ermi PUTNAM.COUNTY HEALTH DEPARTMENT "`'` " °'` ' "'DIVISION OF'ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health NAME ADDRESS - FIELD ACTIVITY REPORT - Sheet of i MAILING ADDRESS P.O. Box Post Office Zip Code TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title .. DATE (5 TYPE FACILITY _j4L,2afV TIME ARRIVED TIME LEFT - FINDINGS:- INSPECTION _ Orig. Routine Orig. Complain Orig. Request Compliance Complaint Comp _ Final Group Illness Construction Reinspection Field, Sampling Only _ Field Conference Other ell Explain f A INSPECTOR: Signature (#�pd Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this SIGNATURE: Field Activity Report .................. TITLE: n /ee TELEPHONE: KC, MLLR�_s!�7_ z TA 1 2 I:.M,T "«� ILI I f A INSPECTOR: Signature (#�pd Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this SIGNATURE: Field Activity Report .................. TITLE: n /ee TELEPHONE: DAVID D. BRUEN County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services August 5, 1986 Samuel Gross Northway & Tanglewylde Lake Peekskill, New York 10537 Dear Sir: JOHN SIMMONS, M.D. Deputy Commissioner RE: Proposed Well Construction Application # W-7 -86 Gross,Northway /Tanglewylde (T) L. Peekskill Review of the above captioned application has been completed. /Additional information or clarification is required as checked below: V 1. A detailed reason for drilling the well is required. A short narrative is required. For what purpose will the well be used, i.e., drinking, lawn watering, etc. -,/ 2. Is the site presently served by a well? Explain. V 3. Is the site presently served by a sewage disposal system? Explain. V;e/4. Is the present structure to be reconstructed? Expanded? How? 5. A sketch showing the location of: _. .� � . _...._.... _ - ...,.�_th� Fropessed•wa�k ,,.... .. _., .._...�.... ......_ . _.. _..._.. -- ;.-..�_ _ _. - _..,�_. -... .__,�_....._ _ .... the existing sewage system on this parcel - the existing house on this parcel - existing sewage systems and wells on adjacent parcels within 200 feet of the proposed well. /- all of the above is not provided. 6. The sketch provided is not sufficiently detailed. See #5 above. Upon receipt of the above information this application will be considered further. ge trul s, Karell, Jr., P.E. JK:mk Director Environmental Health Services cc: Bldg. Insp. F/L /jk -3 TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ... ..._. . :s 1 1. C,; �.,.:.��5_�'�. -�. .. .h.. J 0.0. Y`. I! .�1' er^ w' B 'd(R- ) .1 -„•'?i DEPARTMENT OF HEALTH � r Division Of Environmental H%alth Services r TWO COUNTY CENTER - CARMEL, N.Y..10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL WELL LOCATION -STREET—AURESS. TAX GAW NUMBER. TAN���W WELL OWNER NAME. • ADDRESS: l/J�4 Y,<7 A_Z✓Z4 � i Ll�L�' �sIVATE ❑PUBLIC USE OF WELL M, RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 -secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ AMOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR [2/NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY- ❑ TEST /OBSERVATION DRILLING ❑ $EPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL WELL TYPE I 12rDRILLED F-1 DRIVEN DUG GRAVEL F] OTHER IS WELL SITE SUBJECT TO FLOODING? YES. i NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: LOT NO.: WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: Y YES NO F NAME OF PUBLIC -WATER SUPPLY: L � � k f /'j� � TOWN /V /C DI STANCE _ TO PROPERTY FROM NEAREST WATER. MAIN LOCATION SKETCH & SOURCES_OF CONTAMINATION JAW 1/z, Jn� (date). i (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 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. Date of Issue: 19 +a� Permit.Issuing Official Permit is Non - Transferrable.