HomeMy WebLinkAbout2415DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
50.16 -1-4
BOX 21
'.�M . '
.,' , '��, �.t . ' go
orI - ' 1 ' I'
r A UL
02415
DEPARTMENT OF'HEALTH
Division of Environmental Health Services
110 OLD�ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION. TO .CONSTRUCT.. A WATER_ WELL.y _. --
......._ PCHD PERMIT
WELL LOCATION
Street Address
n
To Villag City Tax Grid Number
WELL OWNER
Name'
IV q.SSA IC✓
Mailing
a 14 A
Addres
Uh,�. +
rivate
0 Public
USE OF WELL
1 - primary
2 - secondary
12�RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑PUBLIC SUPPLY ❑AIR /COND /HEAT PUMP
❑ FARM 0 TEST /OBSERVATION
CIINSTITUTIONAL ❑ STAND -BY
❑ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
i,
YIELD SOUGHT
54 gpm /#
PEOPLE SERVED 44
/EST. OF DAILY USAGE fdi)_gal
REASON FOR
DRILLING_
REPLACE EXISTING SUPPLY
❑ NEW; SUPPLY NEW DWELLING
❑ TEST /OBSERVATION 12-ADDITIONAL SUPPLY
13 DE EN EXISTING WEL
DETAILED
REASON FOR
'DRILLING
.
C-6fia,
o 1
I
WELL TYPE
PDRALED
ODRIVEN
DUG
GRAVEL
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:,
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
[]ON 'SEPARATE SHEET
-7 LM Q
(d te), `Ts
re
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted Linder 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 appl i cant shall :
1. Pump the Well until the water is clear.
2. Disinfeet','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 pro ided by the Putnam County
Health Department.'
Date of Issue: Z 19_�
Date of Expi rat; on. 19• ermi —FIS sui ng
Wbite
Permit is Non - Transferrable copy: H.D. File
Yellow copy: Building Inspector
Rev. 10/88 Pink Copy: Owner
Orange copy: Well Driller