The URL can be used to link to this page

Home My WebLink About2615DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -5 BOX 22 02615 J'h rwiH i . goal is r, I. Ir -:�,� IN Ir 02615 J DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 .(914) 278 -6130 °' - APPLICATION m^ =CONSTRUCT A- WATER. WELL PCHD PERMIT. # W- WELL LOCATION tree�t /A'd/drj�ess ��J // /u� -Tp Villag// C y led-7f Tax Grid Number WELL OWNER Name M g Address aili A `� � ✓! -" e-S e- S' - Wrivate . O Public USE OF WELL 1- primary 2- secondary *RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED O BUSINESS O FARM O TEST /OBSERVATION O 0 R (spa fy 0 INDUSTRIAL U INSTITUTIONAL O STAND-BY O AMOUNT OF USE 7Y YIELD SOUGHT ti]] gpm /# PEOPLE SERVED J /EST. REPLACE EXISTING SUPPLY O TEST/ OBSERVATION ❑ NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL OF DAILY USAGE gal E2, ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING QL „b we.-1 I VA1. I C M L d> T o , �.. WELL TYPE DRILLED DRIVEN ODUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 6/0, / WATER WELL CONTRACTOR: Name /f7ia.'{01rnj, AhdoL -g©y, Address:_ „�'Ha�ri ll��f T IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ENO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY AYSTANCE.TO.•PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH SOURCES OF CONTAMINATION PROVIDED LJ ON SEPARATE SHEET dat (signature) 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 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 ail water or waste products from such well dril g operations be contained on this property and in such /manner as not to degrade or o er se contaminate surface or groundwater. Date of Issue: ! 1913 � ZVA Date of Expiration 19 P rmit Issuing Official Permit is Non - Transfer able White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PARCEL C �s i I! O A C S4 A C R E S o 1�� CJ = H I y � PARCEL 'A AREA= 1.000 A C K E 5 00 w =1 1 —�°% u r 1 °p p. _ 41 �'� \�, W ,+� f R►uE ; `; X/" - - - - 6 `'y 69 t 5 �Nf.0.S *ELL%UG �C' N1 y E �r s �sN ro ti 4Y�1 9- - ° I'` I lA.��j�,�+� —ivZ v+ - L` \1�. �1• ZCV Z f.`. R��p g 210, GG z¢ 4 _ U oss ! E L GL i o ' S a �Oe W i. �E '.s5 14 4 1 ysA G.7 'ro 1 PeLE �iaES eFO�L+ '11.07 N0 00 *o Ro O�ti ELEGfn�G j.0 I 01 ' �E •Z� N O 1 E may_ R(� ' SURVEYED pS IN POSSESSION. c 228.99' C R w f GE °f e. 3G. 37 p1fREn tL� (�'•;)6 POSSESSION ONLY WHERE INDICATED. g ENC0.0ACNMENT BELOW GRADE , IF ANY - 'J= 3s' 00" E (i FORMERLY �?�- aN�s Now �R :,p N 0 1 5 HOWN uEREON.