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85.05 -1 -52
BOX 34
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�i NAM CO DEPARTMENT OF HEALTH
PUT LINTY
�2 DIVISION OF ENVIRONMENTAL HEALTH SERVICES
�. ��....
A-PPLICATION 'I'O CONSTRUCT A WATER, WELL
Y please print or type a _ PCHD Permit #
Well Location:
Street Address:
Town/Village Tax Grid #
/(SPL T_ o k
kA hcfnq Map -
Block�� Lot(s)
Well Owner:
Name:
Address: l 1 s p t, ,— I,--
k
P4L_f VA.LL4EX
HY 10S_
Use of Well:
Y 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 3 v o gal.
Reason for
y Replace Existing Supply Test/Observation
- Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
1ST / &
L
&�'
for Drilling
Well Type
Dril
en Gravel
Other
Is well site subject to flooding?
......................
Yes No
Is well located in a realty subdivision? ......................................
...............................
Yes No r/
Name of subdivision
Lot No.
Water Well Contractor: &og /h.4 A(
AkIm=Qsosi Address: q Aft-CH Jf
/// & Palnam
Is Public Water Supply available to site?
.................................. ...............................
Yes No
Name of Public Water Supply:
Town/Village
Distance to property from nearest water" main:
Proposed well location & sources of contamination to be provided on separates t/plan.
:: - -- ADDljcant Sianatitre:_�_ - - �,
fak:. -��
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
providedjby the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall 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 Fsurface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
constructioIwof 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_1he- Public Health..Director. Any-revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam
County.
Date of Issue C. r %� �j��' Permit Issuing Official:
Date of Expiration Title: �`✓
Permit is Non - Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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PRELIMINARY
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TOWN OF PUTNAM VALLEY
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sURV�y of �/QO��RTy
"All certifis�ations hereon are valid for the map and fil GREPAREO FOR
copies t1:ere,(?f only if said map or copies bear the
impressed cf the surveyor whose signature.appea ^s Ja
here u::.
s /TUAT //t/
SURVEYED .& PREPARED BY 740 �®v' v ` ®� #` 407A " MY �_ 1. E�
BUNNEY ASSOCIATES ®�
ENGINEERS & SURVEYORS
156 KATONAH AVE. 929 MAIN STREET
ATONAH. NEW YORK 1051? PEEKSKILL. NEW YORK 10566 �• /
.drov9/r1`>`o o'ofa: ✓F/N. z7, /972
SURVEYED AS IN POSSESSION FILE No./--_X O;,3
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