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BOX 32
04193
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO.:;CONSTRUCT A:.WATER'WELL
PCHD PERMIT #
I
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WELL LOCATION
,,Street Address ,f Town Villag City Tax Grid Number
���JR� ���Q AE 3; a - >. Z
WELL OWNER
Name
_PAkV4`)drA0
Mailing Address
IlArb C-c /
JWrivate
O Public
USE OF WELL
1 - primary
2 - secondary
Ef RESIDENTIAL
O BUSINESS
D INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
O ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT_�gpm /# PEOPLE SERVED ' /EST. OF DAILY USAGE J� Sal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY 13 TEST /OBSERVATION D-ADDITIONAL SUPPLY
0 NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
fir/ Y
_
WELL TYPE
2DRILLED
DRIVEN
F]DUG
GRAVEL.
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:
'
ress:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: To M M 0 % TOWN /VIL /CITY
DISTANCE•TO.PROPERTY FROM NEAREST WATER MAIN:
._
LOCATION SKETCH & SOURCES OF CONTAMINATION
[]ON SEPARATE SHEET
(d te)
PROVIDED
a/,�z —
(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
thirt3• (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 s ndwater.
Date of Issue: O�' C��S� 19 f;
Date of Expiration 19
Permit is Non - Transferrable
3/89
Permit Issuing Official
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
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- - - PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL A.DDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project05 414040 `f (T)(V) TM#
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes) ~
1. ❑Hilly ®Rolling ❑Steep Slope Gentle Slope ❑Flat
2. OEvidence of wetland ®Low area subject to flooding o ' s of water
❑Drainage ditches Clock outcrop
U
3. Property lines evident?
4.. Water courses.exist on, or adjacent to.parcel:
5. Existing individual wells within 200ft of the existing SSTS? O
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. OLevelOofen le Slope ❑Steep slope
B. ❑Well drained / Perately well drained
❑Somewoorley drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
OExtremely limited 0296what limited ®Adequate _ft x ft
D. INSPECTION Date/ Spector
0'136o evidence of failure DEvidence of failure ®Evidence of seasonal failure
re"y ev
- - ----5 ----------------------------------
(Indicate Norffi)
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low
-------------------- -------
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
etal ®Concrete ®Plastic
B. Type of abso"&n area
1. Fields. 2. Pits 3. Gallies
(2)1 ial6ate-ntbA&ks, fronrstieet, backyard; and sid e ydrd-diffi6nsions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams /wetlands)
SECTION E. EXISTING WATER SUPPLY
DPWS ®Shared well Individual well
®Drilled ❑ DCasing above ground
COIMIVENTS :
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Mr Salvatore J;
;1229 40th St. Mannucci
Brookl ri,. `
Y 'NY 11218
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nucci
1229 40th St
Brooklyn, NY 11218 193,
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S P O. Box 179
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29 40th Sl
rooklyn, NY 11218 -1936
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva . Road, Brewster, New York 10509
(914) 278 -6130
Norman Anderson
152 Barger Street
Putnam Valley, NY 10579
Dear Mr. Anderson:
BROdE R. 'FOLEY;
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10,509
(914) 278 -6130
:. APPLICATLC?N , :TO:. CONSTRUCT - A -.WATER WELL`" <:
vrun DLD1uTT a
WELL LOCATION
Stmt Ad ess
vZ0
To V llage ,Cf
Tax Grid Numbe
WELL OWNER
" ",Name
Mailing
Address V?rivate
O Public
USE OF WELL
1 - primary
2- secondary.
B- RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
0PUBLIC SUPPLY ❑AIR /COND /HEAT PUMP ❑ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
b INSTITUTIONAL O STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT
S1-1 gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE 4&0 gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY
NEW SUPPLY
O TEST /OBSERVATION Q ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
ODUG
GRAVEL
O 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
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: r. _
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O 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 of the completion of water well construction, the applicant shall:
1.
2.
3.
Pump the well until the water is clear.
Disinfect the well in accordance with the
Department attached to this permit.
requirements of the Putnam County Health
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:
Date of Expiration
19
19
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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1 S. J. PAannucci
l CL S .Q .S`, -�iVZ /� S ( �,yE�l C� f 1229 40th St.
(/ � Brooklyn, NY
11218 -1936
WtLL LOCAL
BY TOWN
TOWN OF PUTNAM
VALLEY - LK. PEE KSKILL
VIN 8 RDES WATER DISTRICT -VAC
PROF' 3 • so
WELL
Spry
ITED 2
OC ON 200' '
1 .5
TOWN Of
PUTNAM
VALLEY =
PROP. VACANT REPUT:
IOOI SDA 1 SDA
83. Bo ,Z S
NFU T� �J
,DOWN
VACANT E[R. BG — /_�p T SHAVEEPNUOEOWeLL
A �,
JOSEPHINE MANNUC._ �®
J. R L. FdANNUCCI
100'
VACANT
DEPARTMENT, OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914). 278 -6130
PROCEDURE FOR NEW WELL PERMIT APPLICATIONS
BRUCE R. FOLEY, R.S.
Acting Public- Health - :Di hector f;.-
1. Well permit application is to be submitted along with fee, if required.
2. Locations of all sources of possible contamination within 200 feet of -the
proposed well location are to be shown on a plan or tax map.
3. Contiguous neighbor notification is required.
4. Feasibility of well 'location is to be confirmed by a representative of this
Department.
5. If the proposed well is within 15 feet of the property line the approved well
location is to be staked by a licensed surveyor. If the proposed well
location is within 100 feet of any source of contamination the well location
is to be staked by a Licensed Engineer, Registered Architect or Land Surveyor
prior to drilling.
6. As built and well log to be submitted no later than 30 days after completion,
by permittee.
BRF /RM /jp
August 1995
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