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HomeMy WebLinkAbout3917DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdor-s.com 631- 589 -8100 83.20 -1 -25 BOX 30 03917 girm I- 1 I'� {� ' T ' 16 I I I' r',f '. . 03917 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 ',APPLICATION.. TO CQNSTRUCT..R„ PCHD PERMIT WELL LOCATION re dr sq, To .� City Tax Grid Number a ,_s- voe) WELL OWNER M 11in Address rivate Public USE OF WELL 1 - primary 2 - secondary , IDENTIAL O_BUSINESS O:INDUSTRIAL O PUBLIC SUPPLY O FARM [3 INSTITUTIONAL O AIR /COND /HEA PUMP O ABANDONED O TEST /OBSERVATION O OTHER (specify O STAND -BY O AMOUNT OF USE YIELD SOUGHT S`" gpm /# PEOPLE SERVED /EST. OF DAILY USAGE —r0'0 al REASON FOR DRILLING PLACE EXISTING SUPPLY ❑ TEST /OBSERVATION LZ ADDITIONAL SUPPLY SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN EIDUG OGRAVEL 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,Z , Z& c, Address:/ IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER .MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET �) d te) (signature) /,1611, /-2 Roo A M /.0 //W)R D h?) MY-9- f� i!5� DS 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 drill' g operations be contained on this property and in such a manner as not to degrade or of rw/'be cont a ate surface or groundwater. Date of Issue: 19 4_3 Date of Expiration /i 19 At- Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 0 (FI i . l/ • ice` X / / \ � 4A. t: i RT OPEN a . USE _ Ofo,50" 4J 07 10" W LO IrA .0 L, PEEKSKILL r �'� / 1-9 C-0 C3 nqbs�p Al- ovo - ,Lot -TORY co Ems- WA. 5'►11000 NORSE C)l OpEr; qk S, a 40150" W. OG 0 K L 'F Z- 3A ".0 LEON cc 7�x 4,4 DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 Norman Anderson Inc. 152 Barger Street Putnam Valley NY 10579 JOHN KARELL Jr.. P.E. M.S. Public Health Director :... _: December 10, 1993 RE: Proposed Well Permit Hoetzel (T) Putnam Valley Dear Mrs. Anderson: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: 1. Location of the existing water supply has not been noted on plan. 2; The preposed well - l.ocationlis_ -_ with -in 100, _feet-- of. separation :between :a well and septic system. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Very truly yours, Robert Morris Assistant Public Health Engineer RM:mk SSDS