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HomeMy WebLinkAbout1133DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -10 BOX 11 01133 WELL LOCATION WELL OWNER DEPARTMENT OF HEALTH Division of Environmental Health Services f/ 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT $' Street Address Town/Village/City Tax Grid Number 4 Ottawa Road Patterson, NY Name Mailing Address O Private Kevin Callaghan, 4 Ottawa Rd., Patterson,NY 12563 0 Public . 'USE OF WELL RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP D ABANDONED 1- .primary 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify 2- secondary 0 INDUSTRIAL b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT Jr gpm /# PEOPLE SERVED t /EST. OF DAILY USAGE /00 Bal DRILLING DETAILED REASON FOR DRILLING WELL TYPE EXISTING SUPPLY O TEST/ OBSERVATION LJ ADDITIONAL SUPPLY ®DRILLED DRIVEN ODUG O GRAVED 0 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_RPaI R gnnS_Tnn Address: J/.,p„tnamA -yP__ raw a +r�r N� 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 OON SEPARATE H E, CK T oA (date) s nature) 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 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 ner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: X Date of Expiration 19. Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller