HomeMy WebLinkAbout3334DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
73.05 -2 -14
BOX 27
I
tt 0,
03334
X,
ly,' T
1
w-
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APrLlI:Ai"1UN "'i'U C15N5'1'1tUC`1` 'A"
- WA1'�ER 'W!;LL
PCHD
PERMIT
WELL LOCATION
Street Address
Town Village City
Tax Grid Number
WELL OWNER
Name
A/ i- L t
Mailing
Address
j1/ U L1C.2..� lei
O Private
OP ublic
USF�OF WELL
1 ✓ ✓✓ primary
2- secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /#
O REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING
PEOPLE SERVED 6 /EST.
O T;KT /OBSERVATION
DEEPEN EXISTING WELL
OF DAILY USAGE _Jgal
12 ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
' > L11
WELL TYPE
J!fDRILLED
DRIVEN
ODUG
GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 1,-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name t;'I'L' Address: `R� —`
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY --- ---- ......
ARCT 40 wRlYPERTY FROM Iv FA E;;fi .W:.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
g�ll 7 o �QON SEPARATE SHEET ��=
(date (signature) L
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
third, (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 suc a manner as not to degrade or otherwi c taminate surface or groundwater.
Date of Issue: ZP 19 F3
Date of Expiration t )'o 19 ermit I u ng Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
0 �
r)
0
0 T
r
IX
13 2
JAM
-a./ _ZZ,
Xi
cl
"D
Arn
lj) b
cv,w con
low
\IT Po