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HomeMy WebLinkAbout1105DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.54 -2 -50 BOX 11 no ,,' , i . � I � ff ■ '` , ' I ;rz 7 01105 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT 4 WELL LOCATION Street Address Town/Village/City Tax Grid Number (a I 01 WELL OWNER Name pp Ma�ili`ng Address 1^1 a �HCL 4 -GLavV 4 (o V,.o Q T2o(� "I?oc$VQ -,U0yL OPrivate O Public USE OF WELL 1 - primary 2- secondary OLRESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION O INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD .SOUGHT_ _gpm /# PEOPLE SERVED ,� /EST. OF DAILY USAGE 0U)0 al ❑ REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13-ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING UDLEPENs-?EXlSTXING:rWELL':'. .' REASON FOR DRILLING DETAILED REASON FOR DRILLING - ttz WELL TYPE rpm DRILLED DRIVEN []DUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES V NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name c�rQC� o�t(rra.��,�VQ,Qf�( Address: ©� Lr I IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ C�NO aaS 3LC1 ,NAME OF'PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM.NEAREST WATER MAIN: .LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED � []ON SEPARATE SHEET (date) (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 thirt3, (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 otherw' o)contaqffate surface or groundwater. Date of Issue: 19� IIAI— 1A Date of Expiration 19 !qk_ Permit Issuing Official Permit is Non- Transferrab e White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller