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HomeMy WebLinkAbout2016DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.39 -1 -27 BOX 18 02016 j I -A 1 02016 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 +�- APPLICATION 'TO'� -CONSTRUCT "" At 'WATER' WELL" " "'" PCHD PERMIT WELL LOCATION Street. Address /r 0 Q/t 6OWC Town Village City Tax (ZC sue✓ Al V. Grid Number WELL OWNER Name S C EC 1 t.6 Mailing Address ,Wrivate D ir/ L - Olt Cli Si tk. 4191. /a-S09 O Public USE OF WELL 1 primary 2- secondary RESIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM p TEST /OBSERVATION O INSTITUTIONAL O STAND -BY _ O ABANDONED p OTHER (specif ;y, O AMOUNT OF USE YIELD SOUGHT _ gpm /# PEOPLE SERVED IL /EST. OF DAILY USAGE J a ga. REASON FOR DRILLING VREW SUPPLY [)PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING QifD GJA?P'c- PhFSSt1j? r . _ WELL TYPE DRILLED ❑DRIVEN ❑DUG ❑GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES _j<_NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: _ Lot No. WATER WELL CONTRACTOR: Name Address: Q �u� e'� t�e" 4l' /BSQy _ IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _X No NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION ❑ WS S ET �- 6 -8Z (date) (sign ure) 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 Is sue: ,���,'/ 19 _ Date of Expiration 19 Permit Issuing Offl cia. -- White Permit is Non - Transferrable copy: H.D. File 'in Ye11oW copy. Buz ld g Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller t U S Eb A16' 11-W 101'x� �: .Y(�J+: IfIViI/ Ztj % ;g'G ✓rq �f .