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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO ABANDON A WATER WELL
please print or type
PCHD PERMIT # IS'-10
Well Location:
Street Address: TownNillage Tax Grid #
,y K, -1e (c}' )d r 441A& /-ef Map : Block Lots)
Well Owner:
Name:
Address: ,
Well Type:
Drilled Driven ✓Dug Gravel Other
Depth Data:
Well Depth 6 ft
Static Water Level ft
Date Measured E/6
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:
Name: Address:
A/0 �,�fw"� A� e�, vb
Y►►'�a�+
Reason For .
Abandonment:
Description of Work To Be Performed:
4—
Date: !o Applicant Signature: <
PERMIT
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
'White copy: HD file;
RECD 0 C T
Yellow copy - Building
07 2010
Form WA -97
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usp5 �d e'813yGS�OR3
PUTNAM COUNTY. DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL .,
Dlease Print or tVDe,.�
Well Location
Street Address: Town/Village:
Tax Map #
3 - s3
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a
l- n
of v t I �. a- V Kc .1°t f ev A
Map. Block Lot(s) .
Well Owner:
Nam
Address:
Phone #:
A
/le
Use of Well:
_residential _Public Supply
:. Air /cond /heat pump _Irrigation
1- Prima "ty
Business Farm :.J
Test/monitoring _Other(specify) _
2- Sec9ndary
- Industrial _ Institutional
Standby.
Amount of Use
Yield Sought .. . gpm # People Served
Est. of Daily usage gal.
LLZReplace Existing Supply Test/Observation Additional Supply
Reason for Drilling
'J New Supply (new dwelling) Deepen Existing Well
Detailed Reason
yv
for Drilling
Well Type
Drilled Driven Gravel
Other
U
Is well site subject to- flooding? ........................................................ ............................... Yes _ No,7_
Is well located in a realty subdivision? ....................................:...... ...............................
Yes No
Name of subdivision
Water Well Contractor:
Lot No..
Address: 'S� L5�t
Is Public Water Supply available on site? ....................................... ...............................
Yes No v
_y
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on
separate sheet/plan.
Date: o b Applicant Signature: I 1h- Vr�lt��,X/IA_
W/A
PERMIT To GON5TRUGT 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 Department.
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 tears 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 alter tion of the approve Ian requires a
new permit. Well to be constructed by a water well driller certified by Putnam Co nty.
Date, of Issue to \ �� Permit Issu' g Offic'al:
Date -of Expiration —1 ( Title:
Permit is Non - Transferable
White copy - HD file; .Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
RECD OCT 0 7 2010 Rev. 3/06
1A
SHERLTTA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
ROBERT J. BONDI
County Executive
ROBERT MORRIS. PE
Director of Environmental Health
DEPARTMENT OF HEALTH
NormanAnderDsRII KING AND RECREATIONAL WATER
152 Barger Street
Putnam Valley, NY 10579
Subject: Proposed Well Sterling
485 Farm to Market
(T) Southeast
October 20, 2010
Dear Mr. Anderson:
A field inspection was conducted on the above referenced lot by Vincent Perrin, Public
Health Technician. The application to drill a new well is approved with the following
stipulations:
1. The well pump and any electrical components are to be removed from the existing
well during abandonment.
2. A Well Completion Report (WC -97) shall be submitted no later than 30 days after
the well completion by the permittee.
Please contact me at (845) 808 -1625 ext.46235 if you have any questions.
Sincerely
e�r
Vincent Perrin
Public Health Technician
cc: file
110 OLD ROUTE 6, BUILDING 3 - CARMEL MY 10512
(845) 225 -5186 FAX (845) 225 -5418
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RECEIVED 01/07/2009 04:30
09/22/2010 17:26 2127469022 WEILL•CORNELL MED PAGE 01/01
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