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
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