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04106
1�� DEPARTMENT OF HEALTH.
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
�..; •APP•LICATION, =TG m 1 "; °WATER W _ ...:... ,
CJNS��RU @r A" WATER
PCHD PF.RMTT A(1!
WELL LOCATION
Street /Addres}/
4 #%0j /e w !G�
Town /V llage City Tax
�04 L-t e
Grid Number
WELL OWNER
Nam
So /! c �C
Addre s ,p
e le,, e .� er- T, le /l oz
OPrivate
O Public
USE OF WELL
1 - primar
2- secondary
XRESIDENTIAL O PUBLIC SUPPLY O AIR /COND/HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY
O ABANDONED
0 OTHER (specify
0
AMOUNT OF .USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
NEW SUPPLY
RREPLACE EXISTING
O PROVIDE ADDITIONAL SUPPLY
SUPPLY O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
We-27 +.ai2h
r
WELL ' TYPE
®DRILLED
❑DRIVEN
❑DUG
❑GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: o
Lot No.
WATER WELL CONTRACTOR: Name
Address:
.1 ,„ v
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO -J' ,,,,,, e, 04
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DI.c,T�►.Nr� TO PROPER'T -Y FROM..- NEAREST -WA-TnR- X1 A1N -: .....- ... ....�... ..__.._ - n......._ .. _�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
7/ []ON REAR OF THIS APPLICATION ❑ ON S� TE HE
( 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 th Putnam County
Health Dep rt /ment.
Date of Issue: V 19 A yd
Date of Expiration: d/2,3 19 erm t I s, Z.;rngAOf'cia
Permit is Non - Transferrable
v?Y."�'•wrosrl3esi:.:i::' :,.Sgi•c++r, ie.Nw it �w.' ." ..�.iy, "::gj...•.R)ti' � v:�:iii - "R�i:r. piF•'� � .�....,:' w'. ... .. .. ....
.K . _ _ ..'r, r; "Y ".i. �.. .:'+M:A...i:?�dv;5?a _ Y.... ;`�.'.� . .�."�'?� ..�'.`:.r ..',L•:'.; . -iC „4 �`�l?•3•��'.%�?., �..�!.r.:`y+�!h:•:� . ':i�V.jGJ:YC1.ui, ���
x:�• to [:v: \ -;;, ":i:..�::_s:CY..::.c._: .. ..:�
DEPARTMENT OF WLTH
Division Of Environmental Health Services
TWO COUNTY CENTER — CARMEL, N.Y. -__105 (914) 225 -3641
APPLICATION TO ABANDON A WATER WELL
PLEASE PRINT OR TYPE
LOCATION
$ih'cEf AUUHE;;' lie
-�/4 /
4e".21,
/ (;,X GHIU NUA1d'tHWELL
IU14N�YI�litr(� /�<C�r/
Z
e
WELL OWNER
NAME.
`
Z RESS.. .
-e- -
�i: ��
0 PUBLIC
1 G iC
WELL TYPE
❑ DP.ILLED
DRIVEN
�I
^'
� DcG ❑ GR�VEi, � OTS`R
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL ft.
DATE MEASURED
USE LL
RESIDENTIAL
❑PUBLIC SUPPLY
❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
- primar
❑ BUSINESS
❑ FARM
❑ TEST /OBSERVATION ❑OTHER (specify)
2 --secondary
❑ JNDUSTRIAL
❑ INSTITUTIONAL
❑ STAND -BY
WATER WELL
Name:
Address:
CONTRACTOR:
REASON FOR
-
ABANDONMENT: 1&
DESCRIPTION OF WOiK
TO BE PERFORMED:
_ .a..... >._.._.a ..._� ,� a _.__.-- mss..__. __ _. _ -.. _. • - -,..� � - /'��� � - -•b .. -- ,.. . , • , 9 <.�... __ ._ .�:o. -o..
(date) (signature)
PERMIT
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' York 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 :�'v �j _
/OD
"//tee )o 16"nIA I u Q., ALI r/cy,-
k;seT
75"
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