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HomeMy WebLinkAbout2853DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 62.10 -2 -7 BOX 24 I IN f fz :1,� � J F '1 .� i` 'T. ' ., Is , . '. oi 1r 02853 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 _(914) 225- 0310-.- L..:;: �� :�o...,�::;,Y;_;:�i:::��-.._. APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # ld _603"_ Cl, WELL LOCATION Street Addr ss 4EM (C �� +�e wn Villa a City Tax Grid Number VAL (ad WELL OWNER Name /f 40CK Mailing Address SAwn e Private t Publ is (SE OF WELL 1 - primary 2- secondary RESIDENTIAL 9 BUSINESS D INDUSTRIAL O PUBLIC SUPPLY O FARM O INSTITUTIONAL O AIR /COND /HEAT PUMP 1 O TEST /OBSERVATION O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�gal E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 12-ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DDRIVEN ®DUG ® GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: r Lot No. WATER WELL CONTRACTOR: Name AADeR.SOW ,-41.4- � 1 ►� -�+NC� Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _)L__NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION ON SEPARATE SHEET (date) PROVIDED p (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 all water or waste products from such well drilling operations be ontained on this property and in such ma er as not to degrade or otherwis ont in at ur ac roundwater. Date of Issue: /�4�9 A Date of Expiration Ci " 19 Permi j ssuirig Official Permit is Non - Transferrable White co : HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller Formerly Lawson ' Now or former /y Burkhardt " `Dirt : WOfll5'out . -StolI a Ref. Wall ; "-X -cul found Pin 8 Cop \� Stave Rel. Wolf 589°3420aE Drive / i I % on line 218.00' \ Wall on fine '"'WOII Z X- cut found" r11 fine Wo /l 2.5ir -'. :: 3 J.0 in h C y i on W � ..� .,e i c \ono '. a v � °!�• r •C °Hemlock O24 �0 open �•I °'r' 1� W I Porch 14' dory 2 i' i , / iv, ' a� £lame (� it ``Qc � Dwelling a � e / 2 corm. Porch 2 o, Open I \\ 1' e l— Area = 3/, 324 Sq. Ft.' " $ 1 Pin 6 Cop -� Pin 8 Cop1 \ r • / / titi r oSane / P,n 6 Cop —Pin �- SURVEY OF PROPERTY \I� PREPARED FOR x WILL /AM M LOCKWOOD A SlrUArE IN rHE ' CA_ TOWN OF PUTNAM VALLEY . �- PUTNAM COUNTY NEW YORK Notes SCALE /In. = 30 f1. OCTOBER 9 , 1987. I. Alteration of this document, jtxr ci9 by o licensed Land ' 1 " P Surveyor , is illegal.. r ` All rertrficntinn.c or;- valid tc�., his mnn and conies We hereby cerli /y that the survey shown hereon ,,gplllli:;if!! /.•,. .. _. _,_._� _ .....,. .. .�..+ ••_. 6 4 "l. t ,i