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04578
DEPARTMENT OF HEALTH
Division of Environmental Health Services
.TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #W ?>
WELL. LOCATION
Street Address
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Town V' lage City Tax
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Grid Number
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WELL OWNER
Name
ae�� k 0.
Mailing. Address
ter- A•. s r- a
S ic,f s, �.
V-Private
O`Public
US�,P-WL;ffi
�1�-®
2 - secondary
RESIDENTIAL
BUSINESS
® INDUSTRIAL
❑PUBLIC SUPPLY ❑AIR /COND /HEAT PUMP
O FARM p TEST /OBSERVATION
O INSTITUTIONAL CI STAND -BY
OABANDONED
0 OTHER (specify
AMOUNT OF USE
YIELD SOUGHT
gpm /# 'PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
.DRILLING
EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
a A % f
4., a A* a g Z 4
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WELL TYPE
DRILLED
DRIVEN
ODUG
®GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING?
YES �0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name dors J&lg- Address : �� X /��, „c,,9, V t IPA
f
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 REAR OF THIS APPLICATION - LAN. ARATE SH
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(dat ) 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. 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 prov' d by the Putnam County
Health Department.
Date of Issue: 1 ( 19
Date of Expiration: 19 qj
ermit Lssuing Official
Permit is Non - Transferr ble copyiyH.D. File
Yellow copy: Building Inspector
Pink'Copy: Owner
287 Oranae copv: Well Driller
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Public Health Director
DEPARTMENT OF HEALTH
Division Of Environmental' Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
October 31, 1994
Norman. Anderson
Barger Street
Putnam Valley, NY.10579
Re: Proposed SSDS:
LaBermeier
Slate Crossing
(T) Putnam Valley
Dear Mr. Anderson:
Review of plans and other supporting documents submitted at this time relative to
the above - captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands
regulations. You should contact local wetlands officials in this regard."
Mr. Marvin O'Dell, Building Inspector, Town of Putnam Valley must notify this
office and state he has no objection to the above captioned proposed well
location.
Upon Receipt of a submission, revised to` re`flect`'ttie `aticve `cower7ts; �thi s r p --
application will be considered further.
Very truly yours,
Robert Morris, P. E.
Public Health Engineer
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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
FAX COVER SHEET
DATE:
TO: / �E FAX #
JOHN KAhdC -4711 � 1C11Si i'
Public Health Director
sad '� /3a
FROM: Putnam County Health Department
Division of Environmental Health Services
4 Genevan
Road-,,. -Brevvs 22=, N' 40509
NUMBER OF PAGES TO BE TRANSMITTED (including cover sheet)
NOTES /MESSAGES �/1/� /%S ���`� 1i� =�T��
OUR FAX NUMBER IS (914) 278 -6085
In the event of transmission /reception difficulties, please contact
our office (914) 278 -6130
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