HomeMy WebLinkAbout1216DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.63 -137
BOX 12
,i r ,. j�-oA „
him I
�` L mh I
irr
r ,L , L I I
%
:�
01216
.�J
TWO NTY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL 11 QQ'
6 7 9— 3-C a PCHD PERMIT
WELL LOCATION
Street Address
O .K
n Town/Village/City Tax
Grid Number
WELL OWNER
ame
i S -F-
Mai n Address
`I` n'
rivate
0Public
USE OF WELL
01 - primary
2 - secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
C3INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
0 NEW SUPPLY []PROVIDE ADDITIONAL SUPPLY
REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
e
o S
e V a,
WELL TYPE
tT-
I Lai DRILLED
DRIVEN
D "CjG'RAVEL
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
Address:
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
ON REAR OF THIS APPLICATION ON SEPA WET
L
ate) (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 thirty (30) days of the completion of water well construction,
the applicant s.hall:
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.
Date of Issue: L) 2 19
Date of Expiration: �7 19 :515 ermit ssuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87
Pink Copy:
Owner
Well Driller
�h.
N
grove/ patio
W
N
d'
Q
5 �q.
N7950 -OO "W
o
s ory
a� I from V
/ Fu i u ft dwe //i Fg
o,
1 >', ,Nit w
A
Q
TYRONE (50' wide) : DRIVE
SURVEY OF PROPERTY
PRE / 41?ED FOR
WILL /AM 8 JOYCE ANN C /ACH /N
SE /N6
LOTS A'424 A 426 /NCL
SHOWN ON
"MAP A OF PUTNAM LAKE"
S1 MArE IN
TOWN OF PATTER-SON
PUTNAM COUNTY, NEW YORK
SCALE 1"--20'
Said mop filed Morch 20,1931 as Mop N° 149 H
Legend
stone wo/%
block wo//<
wires ---
iron pin — •
Certified only to.•W171iom,8 ✓oyce Ann Ciuchin, Dote Funding Corp. and Commonwealth
L and rifle Insurance Co. for .rit /e N° R 433 832 P
!,.James C. Edgett, the surveyor who made Note: All, certifications hereon are in accordance
this map, do hereby certily'that the survey with the minimum standards for surveys as
of the property shown hereon was completed adopted by The New York'State Association
June 4, /974. of Professional Land Surveyors and are valid
for this map and copies thereof only it said
map or copies bear the impressed seal of the
surveyor whose signature appears hereon.
CE'tn4'o unauthorized alteration or addition to this
New York License No. 3P12 map is a violation of Section 7209 (2) of
Office of James C. dgett The New'York State Education Law.
Land Surveyors
88A Oak Street, Brewster; New York JOB No. 74043
I�