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BOX 33
'.
ILL I
04430
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
- • -. - APPLI_CATION..TO• OONSTRUCT.. -A . WATER. WELL -
PCHD PERMIT '$
WELL LOCATION
Street Address
�—
Town Village City Tax
vc5 7
Grid Number
WELL OWNER
Name Mailing
a * ri c iL
Address
O'Prrivate
O Public
USE OF WELL
1 - primary
2 - secondary
WITSIDENTIAL ❑ UBLt SUPPLY QAIR /COND /HEAT PUMP
0 BUSINESS O FARM ❑ TEST /OBSERVATION
0 INDUSTRIAL b INSTITUTIONAL ❑ STAND -BY
❑ABANDONED
❑ OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT g'pm /#
PEOPLE SERVED /EST. OF DAILY USAGE 6 gal
REASON FOR
DRILLING
97REPLACE EXISTING SUPPLY
❑ NEW SUPPLY NEW DWELLING
O TEST /OBSERVATION LIADDITIONAL SUPPLY
Q DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
lrytn
Iq V L4 ,
WELL TYPE
DRILLED O DRIVEN
JG
[]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: Name` aa'r�rNcc.,i 1 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >�__NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
❑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 other se contam' to surface or groundwater.
Date of Issue: ,J ZC 19
Date of Expiration j 19 Permle Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. -Insp. Orange copy: Well Driller
�+•La t�. - i* �. � fi• .. �- a ,i, ._ ::n ^,. `ear ...f �.: a' � ,�
r
JOHN KARELL Jr.. P E.. M.S.
.r' = 'i•�- -. .';.� ,. ; .n,e .•Putilic::�Heeltn :biro @tor:;
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
October 26, 1993
Frank & Patricia Yerger
82 Mill Street
Putnam Valley, NY 10519
Re: Well Permit
Dear Mr. & Mrs. Yerger:
A field inspection was conducted by the writer on October 20, 1992. It was noted
at the time of inspection that the existing structure is used year -round and the
existing 35 foot deep well is in direct line of drainage to two septic systems.
Furthermore, it has been stated the existing well has gone dry in the past.
Based on the above, the well permit has been'APPROVEb as a means of supplying
potable water with the following conditions:
1. The relocation of the well is not for the purpose of a future proposed
addition.
sta.rng .e1.1 .as::aba dgri.ed.. ~as:Mpele Pu.triain:CQUnt.jc l e3 :.Departmeiaf,•Codes..,
If you have any further - questions please contact me at ext. 166.
Ver truly yours,
Robert Morris
Assistant Public Health Engineer
RM /jp
PETER C. ALEXANDERSON -4 —_
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
fr-40 �- PA1141A
Dear
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN KARELL Jr., P.E.
Director
V
Re: Proposed -.--n Permit
OV -0
Review of plans dated 4t/>d� last revision dated and
other materials relative to a (Construction permit for the above captioned
property has been completed by the Department.
Based upon such review, and pursuant to the provisions of Article III of the
Putnam County Sanitary Code, you are hereby advised that the proposed method
providing water supply are considered inadequate as set forth
below, therefore, approval of these plans cannot be granted.
CtJucow DIFIG Coo .g-r 5paAA2p'pa d
-ee.7-ki � A VJFa XtJO gG/;rze - ,15Ti 1
0
If you have any questions, please call me at Ext. 304.
Very truly yours,
John Karell, Jr., P. E.
Director
Environmental Health -Services
JK /jp
Form Proposed Construction Permit
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