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HomeMy WebLinkAbout2631DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -20 BOX 22 ■ r It- 66 ' T 6 ■ r 02631 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 PCHD PERMIT # WELL LOCATION � et Address i�c©Pcc ra.�; Town Villa a it Tax pU�T VA4LCY 31,M00 Grid Number 3.5--3- i8 WELL OWNER Name Mailing LV,�I/GLI+I�D itliC ) "e> � Address. °' � �'CDf'C 1' Private O Public USE OF WELL 1 - primary © - secondary p(RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O BUSINESS O FARM O TEST /OBSERVATION O INDUSTRIAL O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# 13 REPLACE EXISTING SUPPLY O NEW SUPPLY NEW DWELLING PEOPLE SERVED 'ry /EST. OF DAILY USAGEA5_V Ral 0 TEST/ OBSERVATION WIDDITIONAL SUPPLY D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING /V e_CP ,''}-MIP -no AIAL. 1414TV19 11rUPP4.:4 WELL TYPE ®DRILLED 13DRIVE14 ODUG C]6RAVEL O OTHER 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 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: /Vii' TOWN /VIL /CITY LISTANCE TO PROPERTY-FROM NEAREST'­ WATER M.AN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED rm ON SEPARATE SHEET (date) (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 thirtir (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 otherwise contaminate surface or groundwater. Date of Issue: 199 Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller MARVIN O'DELL Inspector TOWN OF PUTNAM VALLEY BUILDING, ZONING, AND SANITARY DEPARTMENT April 20, 1990 Department of Environmental Health 110 Old Route 6 I . Carmel,.N.Y. 10512 Re: Proposed Well TM# PV #35 -3 -18 Gentlemen: PUTNAM VALLEY, N.Y. (914) 526 2377 The proposed Water Well site as shown on the attached drawing was inspected on 4/19/90 , and as could be determined was found to be a minimum of one hundred (100') feet from any reported sub- surface sewage disposal area. Applicants that receive permits shall upon completion of construction, submit to the Town of Putnam.Valley (Building Department)a copy of the well drillers Log _:.. _-- --- -- - - -- ------_- a- nd--- Wa-te- r-- a.n- a- lys_is -- report ._- be.- f- ore - -s- aid- we11__- is-- pu-t - -- , - - - -- in service. �` $ AV/1L. MARVIN 0 D LL Building Inspector MO'D:es NOTE: Consideration in placing this water well should be made,that use of adjacent undeveloped property is not jeopardized. 4 (-07 posslu& �/m chwo -r� D, vu f tit 5�Fp 7-t c- - ---------------------- It-n 0 LfK6' T(-'�44 D, vu f tit 5�Fp 7-t c- - ----------------------