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BOX 34
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04456
SHERLITA AMLER, MD, MS, FAAP. a s ROBERT J. BONDI
Commissioner of Health * * County Executive
uykhTTA MOLINARI;'RN;1VIaN - .... �� -�• : a . _ - ROBERT MORRIS.jPE
Associate. Commissioner of Health �� Director of Environmental Health
DEPARTMENT OF HEALTH
DRINKING AND RECREATIONAL 'WATER
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
Do. D--A 117011 CAIAII)
41 Mill Street
(T) Putnam Valley
March 20, 2009
Dear Mr. Anderson:
A field inspection, was conducted on the above referenced lot by Mitchell Lee, Public
Health Technician. The application to drill a new well is approved with the following
stipulation:
1. A Well Completion Report (WC -97) shall be submitted no later than 30 days after
- - the.wells'.:c�►�ap;,et_�ll_1>y t;�w
Please contact, me at (845) 225 -5186 ext.2233 if you have any questions.
S' cerely;
Mi hell D. Lee
Public Health Technician
cc:
110 OLD ROUTE 6, BUILDING'3 - CARMEL MY 10512
(845) 225 -5186 FAX (845) 225 -5418
DIVISION OF ENVIRONMENTAL V TAL H_EALT SERVICES
Y[ .. .[ • m�rA . - is 1[:' - a; .e t_�
APPLICATION TO ABANDON A WATER WELL
please print or type
PCHD PERMIT #
Well Location•
•
Street Address: Town/Village Tax Grid #
f` l/
e•e I kl�,gi i.. (%'t - Map Block Lo4ls
Well Owner:
Name:
etr, le- tr � la w
Address:
L�/ M; St- /04 ha in ur, /bt �
Well Type:
Drilled Driven V Dug Gravel Other
Depth Data:
Well Depth ft
Static Water Level ft JDate Measured
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Abandoned
1- primary
Business Farm Test/Observation Other (specify)
2- secondary
Industrial Institutional Standby
Water Well
Contractor:vw�a:�.
Name: �j Address: f
Reason For
Abandonment:
&A 47 rq
/
Description of Work To Be Performed: ,7 .
e
4-0 ^�
_ .. :.. -
. Z-A
\A) �,�K W
N
r
w
Date: �l �' Applicant Signature:.
PERMffT
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 Permit Issuing
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well
Form WA -97
yo�A' uses N� I ()
��' I PUTNAM COUNTY DEPARTMENT OF HEALTH
\b\�� DIVISION OF ENVIRONMENTAL HEALTH SERVICES
please print or type -APPLICATION Tb CONSTRUCT A UVATE� WELL
%CHDPermi# ..1
Well Location
Street Address: Town/Village: Tax Map # / S-
�I "i fLL St2.Q� PV I IVA4 A Block i Lot(s)
UL
ap
Well Owner:
Name:
Address: t
Phone #:
Cofelf,z- 4'01 -OL4-1
52 S 04 -.
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 Est. of Daily usage
gal.
Leplace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel t-- Other
Is well site subject to flooding? ....................................................... ............................... Yes —
No ✓
Iswell located in a realty subdivision? ........................................... ............................... Yes _
No
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available on site? ....................................... ............................... Yes _
No
Name of Public Water Supply: Town/Village
8
Distance to property from nearest; water main:
`Q
Proposed well location & sources' of contamination to be provided on separate sheet plan.
ij 1c. _ .. �.
pate :...a.. ... � Applicant Signature•_:._
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmei
take appropriate action to assure that any and all water and 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.
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless 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 Commissioner of Health. Any revision or alt ation of the app rov d plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam upty. / o
Date of Issue ` ( C
3 7r L Permit I
Date of Expiration , Title:_
Permit is Non - Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - OwneVOrange copy - Well driller
Form WP -97
Rev. 3 /06
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