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HomeMy WebLinkAbout4835DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New-York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL 4/ PCHD PERMIT #bL11-1P WELL LOCATION Street Address 210 Lakeshore Town/Village/City Tax Grid Number Drive Putnam Lake WELL OWNER Name Mailing Fred Raiwh c oConsolidated Address 230 S.E.. 4 IMPIdvate Blueprint /Ca eCoral Fl. OPublic USE OF WELL 1 - primary 2- secondary UMSIDENTIAL D BUSINESS D INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED O FARM p TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__�gal Q EPLACE EXISTING SUPPLY O TEST/ OBSERVATION Gl ADDITIONAL SUPPLY p NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING Existing well is contaminated WELL TYPE DRILLED DRIVEN ODUG OGRAVEL 0OTHER 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 P . F .Beal &Sons , Inc . Address: 4PutnamAve . , Brews t er, NY IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED f' ON SEPARATE SHEET 11/19/93 (date) si nat e) 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 thirt -y (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 such a manner as not to degrade or otherw' a contaminate surface or groundwater. Date of Issue• l t 19 Q < Date of Expiration X %Q.( Q 19__ ermit ssuing Official Permit is Non - Transferrable 3/89 White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller "T a y M Ivm� I EM