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83.73 -1 -35
BOX 31
04109
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04109
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. - APPLICATION_TO _CONSTR.U.CT-A. WATER.WELL --
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please print or type PCHD Permit # , / . -h o�
Well Location:
Street Address: Town/Village , Grid # 2
3S
(X-1 �'k4 ap W .1JBlock Lot(s)
Well Owner:
Name:
Address:
Use of Well:
Residential 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 , .15_ Est. of Daily Usage gal.
Reason for
V Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
S • ` q
vV1
for Drilling
Well Type
Drilled Driven '\,J Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No �.
No
Is well located in a realty subdivision? ...................................... ............................... Yes
Name of subdivision Lot No. _
Water Well Contractor: oymoz Address: tk&A-eAr �FV-
Is Public Water Supply available to site? ................................... ......................... -. - - -. Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
be
Proposed well location & sources of contamination to provided on separat sheet/ plan
...... , ..
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e: -. .. .... - •- A - l:cant �.,3 naza:e:
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Articl 0 A the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Coded qPided
that within thirty (30) days of the completion of water well construction, the applicant or their HVsigAafiid.,.
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance wltl'iiV'
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report4R>i a_forla `
provided by the Putnam County Health Department. During all well drilling operations, the apoicEavar d/or
well driller shall take appropriate action to assure that any and all water and waste products fiat su41rC'-
well drilling operations be contained on this property and in such a manner as not to degrade &'otl> se
k;qVP0itkVFV\ tamisu rfaceor g�our wat r.k " `<
I N: This a relval ex >res two ears from the date issueOR CONSTRUC O pp p y
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 Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a wat well driller certified by Putnam
County.
Date of Issue r` % �Z Permit Issui Official,-,
Date of Expiration Title:
Permit is Non-Transferrable 1 +1
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; (#ange copy - Well driller
Form WP -97
IFU7NAM COItTN7 Y DEPAR7MIENT ®IF HIEAL7H
IIDMSHON OF IENVU RONMEN7AL H EALM SIEIRVRC ES
APPLICATION TO ABANDON A WATER WELL
please print or type PCHD PERMIT # �a
Well Location:
Street Address: Tov✓n/Village e .l� T I Grid #
evj fw�l Block Lot(s)5
, , Map
Well Owner:
a
Address:
Well Type
--,—>< Drilled Driven Dug Gravel Other
IDepth Data:
Well Depth ft
Static Water Level ft
Date Measured
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Abandoned
I- primary
Business Farm Test/Observation Other (specify)
2-secondary
Industrial Institutional Standby
Water Well
Contr'actor:
Name: Address,
` � /1 Y G6 _
]reason For
Abandonment:
Description off. Work To Be Performed:
kewvwe- a�� (2A eJvi�c.& t cm o( .
W 14 c-evv P.A
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a- I,.
Date:
Applicant Signature: r� <
PERMIT
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR
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
I
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97 ;'
t:_:�.
F3itUCE 'R: 'F�L��St`"
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
�O1tET rI{A� ~NIOLII�AR R.i.,
Associate Public Health Director
.Director of Patient Services
Environmental Health (845)278-6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
Re: Proposed Well Pietris
61 Tanglewylde Road
83.73 -1 -35
(T) Putnam Valley
September 19, 2002
Dear Mr. Anderson:
On September 12, 2002, a field inspection was conducted on the above referenced lot by
Daniel- _Ha_dden, Public Health Technician-The ap_pltcati n_t4- replai✓
approved with the following stipulation: _
1. A minimum of 60 feet of casing must be provided for well protection.
As -built plan, Well Completion Report (WC -97), Well abandonment, if applicable, and
water quality analysis shall be submitted no later than 30 days after the well completion
by the permittee.
Please contact the writer at (845 )278 -6130 ext.2235 if you have any questions.
cc: MB, file
Very truly yours,
ZY ,,,, - ,,
Hadden
Public Health Technician
I- acknowledge receipt of:this- report _- SIGNATiIRE;
02/96 Title;