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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER; CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
�LVOVZ �
WELL LOCATION
Street Address
Town/Village/City Tax Grid Number
WELL OWNER
Name
-4k -k- 69
Mailing Address 1
`�U 4 � 6 t� / A L� � I0
rivate
D Public
USE OF WELL-
1 - primary
2- secondary
VIRESIDENTIAL
0 BUSINESS
D INDUSTRIAL
D PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
❑ ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE �d al
O REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION LI:ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING) ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
(DRIVEN
®DUG
®
GRAVED
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: lbri0
Lot No.
WATER WELL CONTRACTOR: Name /dj2W g . Y,7 Address:' jja -cam,. /
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY:., �"0L'— TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM - NEAREST WATER "MAIN':"
LOCATION SKETCH & SOURCES OF CONTAMINATION. PROVIDED
"ON SEPARATE SHEET
(da e) (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
thirt�� (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 surface or groundwater.
Date of Issue: 19
Date of Expiration 19 Permit Issuing Offic
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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MARVIN ODELL
I Bldg. Inspector
JOHN MAHONEY
Deputy Zoning Inspector
C:
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
November 6, 1992
Putnam County Dept,. of Env. Health
4 Geneva Road
Brewster, N.Y. 10509
Gentlemen:
�I
TOWN;HALL
PUTNAM VALLEY, N.Y.
(914) 526 2377
BETTE STOCKINGER
Bldg. Dept. Clerk
Re: Relocating Water Well
Paul Scheurman
18 Poplar Street
TM#91.33-1-7 & 8
The above noted property has been inspected pursuant
to relocating a water well. The present existing
drilled/well has reportedly ceased to yield adequate
supply.
The- proposed relocated well as shown.-on attr4_c .he_d:.-
wing would be of greater distance from any reported
existing sub-surface disposal systems than the existing,
well
Very truly yours,
MARVIN O' DEL
&,,-**'
Building & Zoning Inspector
MO'D:es
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F /LEO /N 914 /5101/ OF JWNO e,-CORD 5 OFF /CE
01- 7-11-- COO/vTy cLER/G, Pell qw COUNTY N.Y.
Surveyer/ February 7117
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FILE_SecC.�._.. BOOK PAGE...._..,56_.__...
SURVEY
OF PROPERTY SITUATE AT
L AI:L PELKSKII_L
TOWN OF PUTNAM VALLEY. PUTNAM CO.. N. Y.
SCALE; I '.ZOO
SURVEYED BY
J. W LBUR IRISH
906 S UT ST., PEE SKILL. N Y.
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q5 -5110 IV ON rIW4,- OF LAVE PEEKSK /LL
F /LEO /N 914 /5101/ OF JWNO e,-CORD 5 OFF /CE
01- 7-11-- COO/vTy cLER/G, Pell qw COUNTY N.Y.
Surveyer/ February 7117
or Edcuord ./ Lr'nch
Cer -fi�e� fo Firsf Fad��o/ Sovrr/ys
arrtl loor> Associofion oFNeu� joi,F Cify
_Surveyed os ir7 Po.�sessior�
L:- ncraaahrnen /s 6e %w gr'OdP ,�o�y,
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FILE_SecC.�._.. BOOK PAGE...._..,56_.__...
SURVEY
OF PROPERTY SITUATE AT
L AI:L PELKSKII_L
TOWN OF PUTNAM VALLEY. PUTNAM CO.. N. Y.
SCALE; I '.ZOO
SURVEYED BY
J. W LBUR IRISH
906 S UT ST., PEE SKILL. N Y.
/ // / �. f.. 6 L,•5. LIC. fro. ]'J)?