Loading...
HomeMy WebLinkAbout3083DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.63 -1 -41 BOX 25 ILT ti � , r ,.�. 03083 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 PCHD . PERMIT~'" WELL LOCATION Strn6eeCet Address (/�) To V^il]l�agge Ctilt%�y Tax ^/ Grid Nu be J �AJ Pi-NAM V /..'LLP- IYb — r WELL OWNER Name t S Mailing Address IAA ' O- 'fT 33 9ZA &A_ 43:Vrivate O Public OF WELL primary 2- secondary O RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__,gal ❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION ' GI ADDITIONAL SUPPLY NEW SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING _s5 -JtJ 9 k P1 I id i Df- e2N A6.TA2._j4r L_or _ WELL TYPE DRILLED DRIVEN DDUG GRAVEL a OTHER IS WELL SITE SUBJECT TO FLOODING? YES _,)<- -NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: '1 Lot No. WATER WELL CONTRACTOR: Name kotMAO % ]Xk� Address: '?j­jPA4\- (JAu&(j IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY a r�r mr .yursRa.,u FtrrOM' I�Fa "BPS'?. 13AT.H;R..MAT. LOCATION SKETC&& SOURCES OF CONTAMINATION PROVIDED W �, „ ON SEPARATE SHEET 1: � -+.•mot (d te) (sig ture) 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 thirt -y (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 any and all water or waste products from such well property and in such a manner as not to degrade o Date of Issue: 3123 19 414 Date of Expiration' �rZ 19 4 shall take appropriate action to assure that drilling operations be contained on this r otherwise contaminate surface or groundwater. Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 PCHD PERMIT WELL LOCATION Street Address � 5E T Village Cit Tax Grid Number ( -r-41 WELL OWNER Namei Mailing Address Q i! IT( Se�J&_A RD %Private O Public USE OF WELL primary secondary SIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP BUSINESS O FARM O TEST /OBSERVATION ® INDUSTRIAL U INSTITUTIONAL O STAND -BY ® ABANDONED O OTHER (specify) MOUNT OF USE YIELD SOUGHT gpm /# REPLACE EXISTING SUPPLY O NEW S.UPPLY NEW DWELLING) L PEOPLE SERVED 4 /EST. OF DAILY USAGE 60f) gal O TEST /OBSERVATION 12-ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL (a snlppu REASON FOR DRILLING DETAILED REASON FOR DRILLING SELL 'TYPE I DRILLED ODRIVEN ODUG OGRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES YNO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name NoRmAM A00re12-Sd1J Address: VV I)jAM VA( -cF_!, IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY j DISTANCE TO PROPERTY FROM NEAREST WATER MAT -N: LOCATION SKETCH A SOURCES OF CONTAMINATION PROVIDED N SEPARATE SHEET (date) (signature) 1 PERMIT TO CONSTRUCT A WATER WELL 'his permit to construct one water well as set forth above is granted under the provisions f Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within airt-y (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. -ing all well drilling operations, the applicant and all water or waste products from such well perty and in such a manner as not to degrade or of Issue: A0 19 of Expiration 19_ qf-_ shall take appropriate action to assure that drilling operations be contained on this of wise contaminate surface or groundwater. ?ermit Issuing Official it is Non - Transferrable White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller 5F '3f 6PA151_Xe-tt99 fipuA i- v4 00 A14 0.$ *S r39 �lSi'iaG'6• , '414 �o-��0 .