HomeMy WebLinkAbout3498DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
74.- 1 -5A03
BOX 28
1 ru
iV,
,
ki
1.
'
■
1
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641
_ ... .,.' -:.. :3++�.Ve.w�;'%..eT- '.r"dF -'-.. �i� :'<'n-iy ^'• +'rwa':..: i, ::— Y::w•.oti'`== ... -.. -,.: —..-:- �-• r ..i�Oni+tsis.�'
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # ��
WELL LOCATION
Street Address
.2-6 R40C. ,¢ ;
Town/Village/City. Tax
i2b . V4 t:r ,
Grid Number
WELL OWNER
Name
6+'S -K
Mailing Address J
)(Private
0 Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
D ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
.j gpm /# PEOPLE SERVED_ /EST. OF DAILY USAdEi&O gal
REASON FOR
DRILLING
13NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY
REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
D TEST /OBSERVATION
DETAILED
REASON-FOR
DRILLING
154 o V' S^
f
�
l i _ Si1t�1MCA c3 S� DID) ' 1 05 �' �° /�,",�j
�c�ti i _ -c �r S0041PQd T
WELL TYPE
®DRILLED
13DRIVEN
QDUG
13GRAVEL
® OTHER ...
IS WELL SITE SUBJECT TO FLOODING? YES >< NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ,.S' c 6 O
J�j' !i SOC -1k=- 7 c/ Lot No. / �o
WATER WELL CONTRACTOR: Name ,%]nAM,W 'AA)Da_,5P� Address: AA- fj1,Ly� S•�: 4A07'• if�4�j
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES i< _No
NAME OF PUBLIC WATER SUPPLY: TOWN /VU /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER TMAIN. '
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
❑ON. REAR OF THIS APPLICATION OON SPA
-
E
(d e) V gnaii rea
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 s.hall:
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 provi M by the Putnam County
Health Department.
Date of Issue: rte_
19
Date of Expiration: 19 9q ermit Issuing Official
Permit is Non - Transferrable
2/87
White copy:
Yellow copy:
Pink Copy:
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
MARVIFI4b'DELL.
Inspector
TOWN. OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
June 19, 1987
PUTNAM VALLEY, N.Y.
1914) 526 2377 .
Robert Morris
Dept. of Environmental Health
110 Old Route 6'
Carmel, N.Y. 10512
Re: Proposed Well - Rochdale Rd.
Pasik /Brown - Putnam Valley,NY.
Dear Mre Morris:
The proposed well shown on sketch drawing dated June 19, 1987
conforms to -the requirements of separation between any SSD
system and,.therefore, would be approved by this:.>De_partment
for construction.
Upon completion, :,.a copy of well drillers log and water analysis
report shall be,submitted to the.Building_Deparment , by the owner .
before the weir ii put in- sexy ce e
Very truly yours,
L MVIN .� -TELL
Building Inspector
MO'D:es _,.,. ;ti E`;Iii '�'►n3S
enc. - Drawing(ld�H ti'P'1�isW4aQ�!►iEd3
03A133N
I
j .
I
o,
f � .. � ; . t�• � ..� _ .. � j
r �,�:1 -.•� .r..�. •_,•�- ..a°.�.�.�r ,. d r t y._�. a .. - h.. wlc n-• -.. i i• +�wr�
• j . 1 "
,. , ._ ....... 'n y
I
e�a IM 1 r
•I�.- � � tr � � j1 t ' III `� a.•�'1Y
ka
rp
It t a
lov •, 1'it
31a Z ,.` t . (,. ,•'M3
I:,y, 1 6. fb Y .•. t z b it3 Siy VS
..v' • . ter' i4 �sr. ei h 7. 1' {') a! i�. Fir,Ar F �'t{fl
:• a r s t t _ W+ i Tit
.,. • i i :s �' 1> i r ,�.S y ISL�tiI i� i .r t:' f� - ...
\ ,y ° : ��r tit• >;, t �I «? r �
7
7•3 f
.1c I
• i AU
r�
ci
h
,
1
rF TI rt�Vt1 i• i ) L ! I i
1 r ...
,
i
I
) _
9 1
i
.. 1
yi 1 1� �(, o i+ at •�IIT � ..
•'Y VA f � '1 4 I