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01353
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01353
DAVID D. BHUEN
.County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
August 28, 1986
Mr. M. Radunovich
3840 Newport Road
Patterson, New York 12563
RE: Well Permit #W -22 -86
Newport Road Property
Town of Patterson
Dear
JOHN SIMMONS, M.D.
Deputy Commissioner
Forwarded herewith is a permit to drill a well on the above
captioned property for potable purposes.
You will note that the permit is to drill the well only and .
is issued for one year. ,
Approval to place the well in service will be granted upon
receipt of the following:
1. Well Completion Report.
2. Result of Bacteriological Analysis.
If you have any questions, please contact me at.ext. 241.
VeiFy truly yours,
:'John Karell, Jr., P.E.
Director
Environmental Health Services
JK:CJ
enc.
DEPARTMENT OF HEALTH
Division Of Environmental HgzA Services
TWO COUNTY CENTER - CARMEL, N.Y..10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL-
WELL LOCATION
STREEI a 5 . 1UWN /Y1LLA6t /L11Y I.1X GRiU NUMIAR.
S 14) 0 2�:Fw p °4 7-/PpP
WELL-OWNER
NAME.. AOORESS:
D�04, -pk 0, %-�' r 9 �--
M sir -
❑ PSIVAT[
❑ PUBLIC
USE OF WELL
I4ESIDENTIAL - ❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS ❑ FARM ❑TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ jNDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF-USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED =/ EST. OF DAILY USAGE oaf.
-
REASON FOR
W SUPPLY ❑PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
DRILLING
( REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DRILLED DRIVEN ] DUG GRAVEL OT' E-v
WELL TYPE
IS WELL SITE SUBJECT TO FLOODING? _ YES _ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: J9N
_ LOT NO _ : fii )R82 - lct f3s
WATER WELL CONTRACTOR: Name t�9. l�Nv °N Address*:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ YES NO •' -
NAME OF PUBLIC -WATER SUPPLY: A-
DISTANCE TO PROPERTY FROM NEAREST1WATER•.MAIN '
..LOCATION SKETCH & SOURCES OF CONTAMINATION•.
(date) t ( 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
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.
Date of Issue: 19
• . �- Permit Issuing --Ogf icia
Permit -is .Non - Transferrable • . i'��S'
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LOT NO. ARE AS SHOWN
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ALL CERTIFICATIONS HEREON ARE VALID
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— I HEREBY CERTIFY TO —
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— I HEREBY CERTIFY TO —
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TIMELY TITLE
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SURVEY FOR
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THIS SURVEY IS ACCURATE
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TOWN OF PATTERSON
GERALD L. LYNN
WAPPINGERS FALLS, N.Y,
sN° 04'.....
PUTNAM COUNTY
N Y RFG 3l1RVFYnR
NEW YORK
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