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HomeMy WebLinkAbout3345DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -236 BOX 27 03345 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 lrlw fidN `20 CUN8TRUCT ''WATeR WkLL__ ......_.. � _ _ _.......z..rt .. . PCHD PERMIT-#U)1 6 ' WELL LOCATION Street 'Address / 17 LvDleo u 7 s r Town/Village/City Tax Grid Number cc �'V WELL OWNER �Name' Mailing v , 6444Se Y oZ v o 7- Address rivate f f ` A. i + &41 LCt �l ltylor7f O Public USE OF WELL 1 ­primary 2- secondary 11 IF l ' O'RfESIDENTIAL O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP O.ABANDONED 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify O INDUSTRIAL O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT /o gpm /# .PEOPLE SERVED /EST. OF DAILY USAGE 2av gal REASON FOR DRILLING U REPLACE EXISTING SUPPLY O NEW SUPPLY NEW DWELLING) D TEST /OBSERVATION 13- ADDITIONAL SUPPLY 9 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING Ec.L ,fit AJS AO&Y - No "147 -6Z .0,v A 4?r3 1cV )3,1)-XIX WELL TYPE ILLED CIDRIVE14 11DUG aGRAVEi< OTHER IS WELL SITE SUBJECT TO FLOODING? YES l,,10"NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No.. WATER WELL CONTRACTOR: Name A101CMp1✓ Avoe;1,fO / -Address: 174e % IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY LkR'9ST .WAT1QRl i ,I : _ _.. . !✓'� i.: � `� r�.'i� _.. .. ._. _L LOCATION SKETCH& SOURCES OF CONTAMINATION PROVIDED fON SEPARATE SHEET ate (sig ure) 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 contained on this property and in such a manner as not to degrade or of ise contaminate surface.or groundwater. Date of Issue: �� 19 q0 ( t L,--� / f zo 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 r ... .:_...tea. _ _ _._ _,...... �. ._ � �..._.. ._..... �. -_.... r-: • ". - .. r• ..._. - .._... .. ..�- .. �:..e_... ,_,_..�. Lao vt: i f 5 t n J . j _ i J . KAI iyymi rkF'liS[HL P 42 �� IV maw s NAME 17; r° 9— %' �.� �� C'� 5'c v PHONE SITE LOCATION ii# 7f MAILING ADDRESS ?7u i N 9m 1 & Z t e Y PERSON INTERVIEWED �i'�i L S Pam Canplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY 3 POP, � O P, PROPOSED INSTALLER PHONE 7 32- 2-8 REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair mus be in same location and of same type as original sewage disposal system. Different locati(� may require submittal of proposal from licensed professional engineer or registered architect. W I - C A PAc-10 1 14 F11•- 'R,-7'67 R S sir 1,A4 AN 0 Oat & 5V51 -5A - Proposal approved Inspector's Signature & rouosal aooroved with the following conditions: Disapproved 1. Procurement of any Texan permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. fivl Jr, VAFA��M �� (e.g.,house corners). three precast 6' diem. x 6' deep 3. System repair to be performed in accordance with the above proposal and oonditions. I, as owner, or repoj,Jjy, �� agent of owner agree to the above conditions. SIGNATURE ,I TITLE4��.,�„� DATE J [PIE'S: Vbite MD); Yellow (fin ED; Pink (APPUa nt) 10 \fie 4'0/ Z�'e� 17 ,\;o •y a'y'e tt Si d •• O L. 6 y d.0 Ni o Y� J' /low \° C ®� may+ 3 _ Z Of y' A� C 1