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HomeMy WebLinkAbout1922DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.23 -1 -12 BOX 17 ME 1 - r :; a ir Is Is jr� 16 IL 01922 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO NTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION -TO -CON NSTRUCT- WATER' WELL PCHD PERMIT WELL LOCATION Street Address 14 Ripley -Rd- Town/Village/City Tax Patterson NY Grid Number WELL OWNER Name Morteza Arvana Mailing hi 14 Ripley Address Rd. Patterson,NY fiVrivate ❑Public USE OF WELL (V primary secondary 1KRESIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY OAIR /COND /HEAT PUMP O FARM ❑ TEST /OBSERVATION C3INSTITUTIONAL ❑ STAND-BY- OABANDONED ❑ OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED . S-/EST . OF DAILY USAGE' gal REASON FOR DRILLING UNEW SUPPLY PLACE EXISTING SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING % Lrio��./�. // A" La -o..�� �'u i f,� �- �'- d•-�. /r✓�rF� � t WELL TYPE ©DRILLED DRIVEN ODUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES x NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name P.F. Beal & Sons,Inc. Address:PO Box B.,Breuster,NY IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES x NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO 'PROPERTY FROM NEAREST WATER MAIN: J LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION O ON SEPARATE SHEET ( ate 1 / 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:.,!'�'G`�/ -2 � 19 19 —� Permit Issuing fficia Date of Expiration: 19 74!!�7 white Permit is Non - Transferrable copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 287 Orange copy: Well Driller PUTNkM COUNTY-. HEALTH, IF - IM-: nj17jqTr)tj OF ENVIRONMENTAL iw-ATrm czR_Px7Tr,-P_o_ John M. Simmons, M.D. Deputy Camnissioner of Health FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME Orig. Routine Orig. Complain Orig. Request ADDRESS No. Street Town qM No. Compliance Complaint Comp MAILING ADDRESS Final P.O. Bcx Post Office zip code Group Illness Construction TELEPHONE Reinspection PERSON IN CHARGE Field,, Sampling Only OR INTERVIEWED Field Conference Name and Title Other DATE TYPE FACILITY X" TIME ARRIVED TIME LEFT I Explain TELEPHONE ELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this eld Activity Report. SIGNATURE: 6/86 TITLE: 41®/ 2 - N/F DONAHUE N/F PE ME N 26 °41'00" W T 5.0' LOT 15' 13' 1 201 �� I 201 LOT C -2901 t 02900 I C -2899 I C -2898 1 C -2897 O. C•2896 11 I I I O n I • 0 � 3 O 0 p 1 I 'l5 .- 151 I 1S 6 °4L0y E 0.17 AC. -&Wf+L PATIO (Bloek) I STY. - -FR. DWO. 10.51 I 20,_l 11 W >.> a� o c� N/ LAN/. v T5.0' R/ PL E Y ROAD (Bit.) (�v1 THIS SURVEY IS ACCURATE r AND CORRECT BY: G/\ ��► GERALD L. LYNN WAPPINGERS FALLS, N.Y. N. Y. REG. SURVEYOR No. 049292 4'tZ ",obl T5.0' R/ PL E Y ROAD (Bit.) (�v1 THIS SURVEY IS ACCURATE r AND CORRECT BY: G/\ ��► GERALD L. LYNN WAPPINGERS FALLS, N.Y. N. Y. REG. SURVEYOR No. 049292