HomeMy WebLinkAbout1293DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.71 -1 -38
BOX 12
I I INS W a '� ,
i ;i T
'
�'6'
= ' �
1
r � I t
0 i
jr
01293
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL l Q
PrUn IDVDMTT 4 I/I -/J/c l / 1
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
78 Warren Drive, Patterson, NY
WELL OWNER
Name
Cathy & John
Mailing Address OPrivate
Bookless ' 8 Warren Dr., Path vs-D11,NY 0Public
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL
0 BUSINESS
CI INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE __gal
REASON FOR
DRILLING
Z REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 12-ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW D ELLING C] DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
/s "---4-AQ PAAvvVT
WELL TYPE
TE)DRILLED
DRIVEN
ODUG
GRAVEL
a
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 _ p _ RPa1 R Snn c _ T r. Address .
'PO Bnx R_ �Brewstav,NY
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 CONTAMINAT TONn PROVIDED
DON SEPARATE SHEET
( ate) (s
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
any and all water or waste products from such well drilling operations be
property and in suc a manner as not to degrade or otherwise contaminate
Date of Issue: 19�
i
Date of Expiration P, to, 19 Permit Issuing Official
action to assure that
contained on this
surface or groundwater.
Permit is Non - Transferra le White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller