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HomeMy WebLinkAbout1163DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.57-1-34 BOX 11 01163 . ,. 11 IL L �. r Ir s r c r +%j . LL k47J6. 01163 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 #w 65-e WELL LOCATION Street Address 32- Town/Village/City Tax Grid Number Dr. Arelds er IV y WELL OWNER Name F} ia..n Lee Mailing Ad ress 32. /-Aid br 6r&--,s'fe,- NY /CZ7 $Private 0 Public USE OF WELL 1 - primary,- 2- secondary O RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION M INSTITUTIONAL O STAND -BY 0 ABANDONED OTHER (specify AMOUNT OF USE YIELD SOUGHT_ _gpm /# PEOPLE SERVED 5- /EST. OF DAILY USAGE gal O REPLACE EXISTING SUPPLY O TEST /OBSERVATION CIADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN []DUG O GRAVEL O OTHER IS WELL SITE SUBJECT TO FLOODING? YES . X, NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ''d' Lot No. �� p WATER WELL CONTRACTOR: Name �-/ 1 PAX JV �'�1 / C° Address: 4f" IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE -TO PROPERTY . FROM­ NELRE. ST - WATER - MAIN: ...._ .... _..._. _...._ ..... . LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET I �n� & �1 _ZILA, „( (date!) (sig ature) tv 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 Department attached to this permit. 3. Submit a Well Completion Report on.a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant any and all water or waste products from such wel l property and in such a ma per as not to degrade o shall to appropriate action to assure that drill id o erations be contained on this r'other "* e ¢ontaminapA^Q surface or groundwater. Date of Issue. 1411419 Date of Expiration 19 Permit Is uing Official Permit is Non - Transferrable White 'copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller