Loading...
HomeMy WebLinkAbout1362DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.79 -1 -16 BOX 13 L - 1 T J �' t lAJ em � ,- ,A gil' 4 .L�"'f i + �� 941 + pp - mi All 01362 v. v. . •: �c_.k: _ ry�ey ;a' "�•.�.t+ a.:MRv::. DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL q PCHD PERMIT WELL LOCATION Street AAdress f - 1 > Tom a ty Tax Grid Number WELL OWNER ame Mailing Address 1�,,, ! )WPrivate O Public USE OF WELL 1 - primary 2- secondary JMRESIDENTIAL O BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY O FARM M INSTITUTIONAL O AIR /COND /HEA PUMP O ABANDONED O TEST /OBSERVATION O OTHER (specify O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED -- -/EST. OF DAILY USAGE S5,.) al O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 'ADDITIONAL SUPPLY. O NEW SUPPLY NEW DWELLING1 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE QDRILLED DRIVEN []DUG GRAVEL 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 Address: 52, IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 0 v ,� NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DIST'A'NCE- T^ - PROPERTY FROM NEAREST - -WATER MAIN.: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET (date) (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. 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 suc a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19� Date of Expir ion 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 s Y iii q � STS O-c .947 th.-• `l9ET y ��hdS 11:::7e 4e e .�• j O F�r�4'9'Y— L,rpE9 jO6 j ! 1 ,S4y PillOr 6 -2351 ale o c �L k f uT;,r,Y p i l l er is A61q s \ \ o �� °tai e` `fi • g0� 0 o z l r S Q j noN `et. 5 of �t✓l[ P? 9 ° °1 -� m N 6 G OTS 8 -2291 ,y9 O a, o ° o .� -`__nn9 °�O aT •� \ ot001 Pin f.tl. • °t° m L OTS B 2285 /'U 227e of � OJ 7 m d � V� "► P'4i9CEL SHO.i✓N DESIGNATED AS LOTS <B- 51 TN.9!/ .Sff0�4N ON .4 f1�4P L ENTITLED, %'SAP B1 3� T�T�4� j CLO O LSO B � 6 A 4� B 75T TO t0 �y ypyy LOTS B 8- 3441 INCL . , DATED /W V,C5� 17. �9�f '4N0 FILED IN T�`/E Pl/TNf1f1 COUNTY CLE OFFICE ON wlWsT 19, 19 1 AS FILED �1AP /149�i