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03934
DEPARTMENT OF t- iF�ALTH APPENDIX P
~ Division Of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. .10512 ( 014) 225 -3641
�1PPLIC'AlTeN ^T`0 �.;3AN� •N
- :� :e r.r, -�,, _..., _ �.a •- r O A •WATER WELL ,
• PCEASEPRINi OR TYPf -. •• _ - -_ M � -_ •• - ••
S1F;Eci AUUHE >;.
WELL LocAT)oN / ®y
x „t,IE.
WELL OWNER
WELL TYPE 5d-DRILLED
10MVILL, G601Y
AooaESS.
I:.x GRIU HUAtdci{
❑ PBIVrNTE
O .EUBLIC
L�J DUG E GRAVEL OTH= R .
DEPTH DATA I WELL DEPTH _an, R', ft.I STATIC WATER LEVEL .
USE OF WELL
Primary
2 - secondary
9:RnIDENTIAL
❑ BUSINESS
0 1NOUSTRIAL
❑ PUBLIC SUPPLY
❑ FARM
❑ INSTITUTIONAL
DATE MEASURED `
❑ AIR /COND. /NEA-T-PIJMP
❑ TEST/ 0RSSERVATION
.❑ - TAND /BY
G ABANDONED
❑ ;OTHE,R (specify)
❑
WATER WELL Name: : Address -
CONTRACTOR: T
REASON FOR /'!� vt/ �"� rd �% �r/ G p v► 5 f m c. a1�...% v7 ” o`�� v
nBANDONMEPIT : .
I've
4- -7
)ESCRIPTION OF WORK
CO BE PERFORMED :, /`S `,7� Z-=/ --
C
G ��
(date) _ _ t (signature) - - - -- - 7—
PERM IT
This permit to abandon one water well as set forth above is
granted under.provisions- of Subpart 5 -2 of• Part 5 of the
New'lYork State Sanitary Code and provided that: Within 30
days of the completion of the abandonment-of the water well,
the applicant shall submit to the Department a certified
statement that the information delineated on the application
for this permit has been completed,_
Date of Issue:
=Perini = .Issues ng Official 23
Inspector
I TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
November 2, 1989
Mr. William Hedges
Dept. of Health
1.10 Old Route Six C`enct ' ;dr,
Carmel, N.Y. 10512
TOWN HALL
....... PUT-NAM- VALLEY,
(914) 526 2377
Re: Relocate Well
Eugene'Taylor - TM#80-3-11
Dear Bill:
The above noted proposal to relocate a water well
is not objected to, provided measures are taken to
properly abandon the existing well.
Thanks again for your continued cooperation.
MO'D: es
enc.
You _S
MARVIN O'DE�X
Building eZoning Inspector
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
:''.`....`.' 'Al''iP'I;ICiKT]:'ON fi0 C�1J5TY2�� �A` finTATEIt WELL .
PCHD PERMIT
eGIJ- I19-9Q
WELL LOCATION
104. Stre t Address
LkToMqVil lage/ City Tax
..
Grid ember
+E LL OWNER
Name ' �_ ailing . Address.
1 -T /Oy
) �.
;Private
s O'Public
- rim
SIO ENTIL PUBLIC SUPPLY
BUSINESS O FARM
O•INDUSTRIAL CIINSTITUTIONAL
O AIR /COND %HEAT PUMP
❑ TEST /OBSERVATION
0 STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE ___.gal
rXREPLACE EXISTING SUPPLY O TEST /OBSERVATION 13. ADDITIONAL SUPPLY
I p NEW SUPPLY NEW DWELLING DDEEPEN EXISTING W L
REASON FOR
DRILLING
. DETAILED .
REASON FOR
DRILLING
_
c,
.. Ze
WELL TYPE
' DRILLED
ODRIVEN
ODUG
OGRAVEL
'OOTHER
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:
IS PUBLIC WATER SUPPLY
YES
DISTANCE :TO' PROPERTY -t ROM NEAREST ;WATER MAIN;
LOY-:zw CH & SOURCES OF CONTAMINATION PROVIDED
O ON SEPARATE SHEET
ra
at J6 1 s n e
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
thirt %! (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 a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19
Date of Expiration 19 . %d Permit Issuing Off1cial
Permit is Non - Transferrable White copy: HD File. Pink copy: Owner
3/89 �r r=.' Xo� �..,y� G���gIlo copy: Bldg. Insp. Orange copy: Well Driller
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for
SURVEY OF PROPERTY
Cerfificafions hereon are valid Bank.
FOR
Title Co. & Owners for this transaction
E;
�d,
only Cerf Tica I;, are not transferabl
subsequent Bank. Title Co. or owner, to
6WENE DUDE TAYLOR
All certifications hereon are valid foi4hs
map and copes thereof only ;f said map o
`'^
t,_ -
JOHN SALVATO,R
r E ROMED
SITUATE IN THE
impressed seal of fhr
':� `.
Crmsufting Engineer �i farad Sursryor
.-r—'
copies bear the su
veyor whose signafure ppee s he eori
c 1, NORTHRIDGE ROAD �",
PEEKSKILL.N, y
�c/rnGiv� COUNTY
if is hereby cer#ified tha+ +h s turv�Y was
wth
c '
r•„ NEW YORK
Prepared in accordance.
Code of P-0ice for Land Surveys edo fed
P
by the York State Assoc et on�cOf p
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P: E. & L 5. NYS i . NO. 02 6
New o
fessional land S.rveyOra.• �'1 ^w> 'y
INC ROACHMENTS BELOW G ?A OE IF NpT SHOWN '
SCALE: f
ANY
'
SURVEYED A S IN POSSESSION
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