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00525
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00525
DEPARTMENT OF HEALTH
Division of Environmental Health Services Mary Bridget
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMITl.✓�o�+�'
WELL LOCATION
Street Address
Quaker Lane,
Town/Village/City Tax Grid Number
Patterson, NY 15. -1 -47
WELL OWNER
Name
Klinkenbergh,
Mailing Address ®Private
Frans, Quaker Lane, Patterson, NY OPublic
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
b INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�al
® REPLACE EXISTING SUPPLY O TEST/ OBSERVATION , 12-ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING 13 DEEPEN . E ISTING WELL -
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
IF Has no potable
water. Shallow well contaminated
A ,✓ s W va'% -✓ �- ° S
J
WELL TYPE
DRILLED
O DRIVEN ODUG C3 GRAVED 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 P.F. Bea 1 & Sons, Inc. Address: 4 Putnam Ave., Brewster, NY 1050
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 6 SOURCES OF CONTAMINATION PROVIDED
Q ON SEPARATE SHEET
6/5/97
date) ') ''JJ ( gnature)
Vol ry ^�2iG��bar3 LAP') Pe L. Beal
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 provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall h
any and-all water or waste products from such well drill
property and in such manner as not to degrade or oth
Date of Issue: 19 �i
Date of Expiration 19 r Perm t
Permit is Non - Transferrable White copy:
3/89 Yellow copy
take appropriate action to assure t at
klrg'o erations be contained on this
e ontamina surface or groundwater.
Issuing Official
HD File Pink copy: Owner
Bldg. Insp. Orange copy: Well Driller
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VnaM I S NAME
SITE LOCATI%
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
/� - %/ -0/
PHONE 2'? ri -
MAILING ADDRESS
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY
PHONE T-3d -39 S
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect. �r "el - .. / n : $ 4 J J.�.
Proposal approved
s Siqnature & Title
/00
40"5e-
Proposal Disapproved
rovosal amroved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner r po agent of owner agree to the above conditions.
SIGNATURE TITLE DATE �r
3-CM: * ite (FM); Yell w (Town ED; Pink (.Aftlioant)