HomeMy WebLinkAbout1650DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34.13 -1 -69
BOX 15
01650
I
I I
No
,I No
a
No
' �I
J
rl
�' 1'
.�'
`9.
1
T T
�y . T '
1 .
N No
I
IN
01650
DEPARTMENT.OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. '10512 (914) 225 -3641
- - APPLICATION -TO CONSTRUCF� �A - WATER WELL
PCHD PERMIT #% 1L
WELL LOCATION
Street dress
1.90�
Town/Village/City Tax
w -
Grid Number
-
WELL OWNER
K N e `•
Mailing Address
�3 a u ��e
�Q �Cc.�, Wt
qaPrivate
O Public
USE OF WELL
1 - primary
2- secondary
RRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY
0 FARM
O INSTITUTIONAL
0 AIR /COND /HEAT PUMP
0 TEST /OBSERVATION
0 STAND =BY
0 ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE
SERVED /EST. OF DAILY USAGE SD0 gal
REASON FOR
DRILLING
ONEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY
QREPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
e- t ow - tw SP l YL
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL
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: Name20Uj !4 "LU .CMCd dW . Address: ft5- P-` -;- CAL444 -V
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _A,_NO CXR4 3�q�
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 MON SEPARfTE SHEET
10 -- �. -�t
(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 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 prov' a by the Putnam County
Health Dep rtment. /�
Date of Issue: rD 19 q a, d,
Date of Expiration: o / 19 ermit Issuing fficia
Permit is Non - Transferrable White copy: H.D. File
YellBuildin In 4-^v-
2/87
1
aw copy. g spec
Pink Copy: Owner
Orange copy: Well Driller
Boyd ArteMan efl,
R.Z.. N®. 5. Rt
Carmel, N.Y. 1Q
twit,
(914) 225-31�
ABILITY
ckc)A e-4 It �� ot� COcJ"
- ,ii W,-'Ag Rd
Q VA
r7 r7 Lo+
SPZZ� UZ
IDD
(P-F, -,W) 1 -11