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HomeMy WebLinkAbout2371DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.14 -1 -58 BOX 20 L Al Jr '- i■ ;r T �+ I ir . ' p16 m 02371 AM coG ItIll . TWO UNTY DEPARTMENT OF HEALTH. Division of Environmental Health Services CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL '�,�L/ qq PCHD PERMIT #VIA /,5CO _ n WELL LOCATION Street Address Town/Village/City Tax 14 Arbutus.Rd., Putnam Valley, NY_ Grid Number WELL OWNER Name Mailing Address Joseph.Virilli,2452 Young Ave.,Bronx,NY 10469 QPrivate 0 Public USE OF WELL 1 - primary 2- secondary 13 RESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING EINEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN DDUG 11 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. AddressP.O.Box B.,Brewster,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: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION ® N SEPARATE SHE T i3 � (date) ignature) 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: 6c j� ��- 19 Jy AV Date of Expiration: Gam, 19 j a ermit Issuing Ufprcial Permit is Non- Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller