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HomeMy WebLinkAbout3028DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.18 -1 -42 BOX 25 !!N7%'. ,� ' . ' �. U o ` . L jr rk 7 L , 03028 DEPARTMENT OF HEALTH Division of Environmental Health.Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 ~` APPLICATION, TO -CONSTRUCT -"A WATER WELL' PCHD PERMIT # 110 7S• 9S WELL LOCATION Stre Ad rW Town/Village/City � Tax Gri Number o .WELL OWNER Name Mai 1 g Add s ASPrivate O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY Q AIR /CON /HEA PUMP O ABANDONED 0 BUSINESS O FARM O TEST/ OBSERVATION O OTHER (specify 0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT S� gpm /# PEOPLE SERVED ---- -tEST. OF DAILY USAGE _45V al REASON FOR DRILLING CE EXISTING SUPPLY 0 TEST/ OBSERVATION Q ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING f] DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DUG GRAVEL 0 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 IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: Address: YES NO NAME-OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY e► DI T*PsTO'VROPERTY FROM NEAREST WATER MAIN: - SKWCH & SOURCES OF CONTAMINATION PROVIDED -' U F- 0 O SEPARATE SHEET EEI ta(.di -W.' r v (signature) '•9 l Lu 2� 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 thirt3, (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 haste products from such well drill g operations be contained on this property and in such''' manner as no.t to degrade or oth wi a conta ate surface or groundwater. Date of Issue: 19 g Date of Expiration a 19 .(2 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller G� _I. .. : . �� r •""` -.-- i R�� '�► y�� .�� e ?� i� 0 ' .. . ... 0 • s ,a. ., . M • � 'gyp 0 o s TOO � s� . rl . ;s