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HomeMy WebLinkAbout3960DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.57 -1 -55 BOX 30 03960 IN �ILim Wo �T 1.6 - 'L o : I ��r. IF tip' IN 03960 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION�TO CONSTRUCT A WATER WELL Prue PP.RMTT A WELL LOCATION Street Address San Town Vijlage City Tax Grid_ Number �-�d�2 elks�ril . � Vq-H N• � s 7 WELL OWNER a AW n Nailing Address 303 eeu•er(W 6rovlC h P, Private, OPublic USE OF °WELL l - primary 2._- _secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL_ O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP. O FARM . O TEST /OBSERVATION C] INSTITUTIONAL O STAND =BY O ABANDONED O OTHER (specify, Q - -- AMOUNT OF USE. YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING'-- E] REPLACE EXISTING SUPPLY O TEST /OBSERVATION Ld ADDITIONAL SUPPLY ir L(NEW SUPPLY NEW. DWEL ING O DEEPEN EXISTING WELL DETAILED .REASON FOR DRILLING WELL TYPE , DRILLED D DRIVEN DUG O GRAVEL 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 V 04 -may � o y� Address:.' �ty4r- �'C• y1fih �tvri ' ILL Ile IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO tSMSO nA NAME OF PUBLIC WATER SUPPLY: /,&/<f l��•e. k_5 14 I TOWN LL CITY DISTANCE .TAD - PROPERTY FROM NEAREST WATER MAIN: �J LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED N A q' f �g� QON SEPARATE SHEET (date) (signature) 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 otherwise contaminate surface or groundwater. Date of Issue: c.J ePT 19 F Date of Expirationsb -P 19 Permit Issuing 0 i ial Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller . _ PUTILkM 9" .`Ty- Ty- . LTH '- DEPAIWIENT DIVISION OF ENVIROiAL HEALTH SERVICES John M. Simwns, M.D. Deputy Camni.ssioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME Ni..� Orig. Routine /� Orig. Complain ADDRESS �'�•O v f 0 7 "'/ / ;l Orig. _Request. No. Street IM, No. _ Compliance MAILING ADDRESS _ FCcmplaint Corp P.O. Boas Post Office Zip, Cade _� Group Illness , 'Construction TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title DATE �� % TYPE FACILITY TIME ARRfVED � /, '00 TIME LEFT V'MULNUb �{ Reinspection .Field, 'Sampling Only Field Conference Other Explain PERSON IN CHARGE OR INTERVIEWID: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: i 1 PERSON IN CHARGE OR INTERVIEWID: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 .: APPlCnATION° TO CONSTRUCT- °i1 vVA'f'ER° AiV -- PCHD PERMIT WELL LOCATION Street Addres - Town V 11 ge Cit Tax Gri Number WELL OWNER N eAV"thKr- j G Mailing Address " .;G. �r-vok / rivate .� 44 Private USE OF WELL 1 = primary 2- secondary ;9 RESIDENTIAL Q�BUSINESS 0 INDUSTRIAL O.PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST./OBSERVATION d INSTITUTIONAL O STAND -BY- O.ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 3 /EST. OF DAILY USAGE gal REASON. FOR DRILLING IMNEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY 0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL, OTEST /OBSERVATION DETAILED' - REASON FOR DRILLING .WELL TYPE .DRILLED 13DRIVEN aDUG aGRAVEL ' . C] 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 Address:ALy, s> 4' nkm IS PUBLIC WATER.SUPPLY AVAILABLE TO SITE: YES X_NO Sol, cad NAME OF PUBLIC WATER SUPPLY: f-ai<e t-ee4sj4 I j TOWN VIL CITY "DISTANCE' TO, PROPERTY FROM 'NEAREST -WATER LOCATION SKETCH. & SOURCES. OF' CONTAMINATION PROVIDED AJ ' ✓g. []ON REAR OF ;THIS APPLICATION 110 S PARATE HEET date) signature) 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 d by the Putnam County Health.Department. Date of Issue: IIJ4 19 Date of Expiration: 19 °' Permit Issuing Official -�f White; copy: H.D. File Permit is Non - Transferrable gYellow copy: Inspector 2/87 P:4. -ow: •Owner Orange copy: Well Driller DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER CARMEL,' N.Y. 10512.(914) 225-3641' . ........ . CONSTRUCT WATER R r, P r- 14 T) PERMIT :A* WELL LOCATION treet Addr Ss V V Top la el Ity Tax Gr d Number, WELL OWNER Nam a' U n Address Priiate b-lic, USE OF WELL• - 1`� imary 2 secondary RESIDENTIAL supPT.-Y/ bAIR/C'bND/HFAT PUMP 9BUSINESS 0 'FARM .[]TEST/O'St B ERVATION 0. INDUSTRIAL CI INSTITUTIONAL„ 0 STAND-BY. ABANDONED U OTHER (spec'ff Y: AMOUNT OF -USE YIELD SOUGHT gpm/# PEOPLE.:SERVED /EST.,OF DAILY USAGE 'REASON.FOR DRILLING NEW SUPPLY. REPLACE EXISTING 'OP ROVIDE ADDITIONAL SUPPLY SUPPLY, 0 DEEPEN EXISTING WELL (3 TEST/OBSERVATION DETAILED-. REASON FOR DRILLING A 14 /' k t TOWN /.CITY N S, E TO PROPERTY 'FR'OM- NEAREST MAIN: NP 'LOCATION-SKETCH CONTAMINATIONr PROVIDED WELL TYPE DRILLED 0 DRIVEN ODUG []GRAVEL OTHER IS WELL SITE SUBJECT tO.F]L).0bING?! YES NO IF WELL-IS LOCATEDJN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot NO. WATER WELL CONTRACTOR: Name hne&,qn ArJ�� Address: WATER SUPPLY AVAILABLE TO'SITE: dc=h YES NO NAME OF PUBLIC WATER SUPPLY: 1_X �4k YE f A 14 /' k t TOWN /.CITY N S, E TO PROPERTY 'FR'OM- NEAREST MAIN: NP 'LOCATION-SKETCH CONTAMINATIONr PROVIDED []0 N REAR OF THIS r N. [16 SHEET tu (date) (s ture) WY, �4_ PERMIT TO CONSTRUCT., =, ­.,WATER WELL This permit, to construct one water we1T a.,sg r1h abovei granted under the prov . isio ns of Subpart 5-2 of Par 5 t 0 1 COW k Stat M an tary Code, and 41 W ter well construction, provided that within thirty (30) d completion the applicant shall: - 04" t water i. Pump the well until th*'water sTPar?'' 2. Disinfect the well in facbbrdan '-with the r( gq u i m6p" is of the Putnam r e County Health Depa t nt, a tt a o thts,, rmjjt r me 3. Submit a Well Completion a,.,. b r Health Department.' Date of Issue: 19 Date of Expiration: 19 Permit is Non-Transferrable 2/87 D th y es-Putnam County t '11' 7ss. uing. utticlai My: H.D.Tile popy: Building Inspect-or py: Owner couv! WP-11 nrilla-r DIVISION OF ENVIROaUNTAL HEALTH SERVICES oh"`°z Jahn M. Simmns, M.D. Deputy Camni.ssioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME �- Orig. Routine Orig. Cc mpl.a n ADUff ESS j y s4� r Ro ,�!' �,! Orig. Request No treet Town TM NO. CmVl ance Cc mplaint Comp MAILING ADDRESS Final , P.O. Box Past Office Zip Code Group Illness Construction TELEPHONE Reinspection PERSON IN CHARGE .._ Field, Sampling Only OR INTERVIEWED Field Conference Name and Title Other DATE & TYPE FACILITY TIME ARRIVED 1 2.p © TIME LEFT 12 A 3c} Explain FINDINGS: INSPECTOR: ture PERSON IN aymm OR INTI�2VIE�D: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: TELEPHONE: ,ey. ,:d. 9. °t. � .,� �v�'�rmz�Yi�ixAv� ��is'�'%�i�l4i ➢d!' a lu':�13. ff� -' - rasa a s ..,.. ��A s n , , DIVISION OF ENVIRONMRNTAL HEALTH SERVICES John M. Simmons, M.U. Deputy Co missioner of Health - FIELD ACTIVITY REPORT - Sheet of K - INSPECTION Orig. Routine ADDS IZAX -f -1`7 Orig. Request No.' Street Town 7M No. Compliance O T'+ Canplaint Comp MMLING ADDRESS t , t30. - - J_ 7' r2 a9KL7 �1 _ �� Z Final P.O. Haas Post Office Zip Code Group Illness �---- . Construction TELEPH Reinspection PERSON IN CHARGE Fields Sampling only OR INTEMFEER Field Conference Name and Title Other DATE - TYPE FACILITY �� Ft, • TIME ARRIVED TIME LEE'T Explain PERSON IN CHARGE OR Imo: I acknowledge this Field Activity Report. SIGNATURE; 6/86 TITLE: TELEPHONE: MOUNT OF-USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED _61-1 EST. OF DAILY USAGE o a. REASON FOR NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ;0 TEST /OBSERVATION ORILLING 0 gEPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL WELL TYPE DRILLED v A. r..a k a Y 44�t' �"`^.+ ya., r^!°' FF�rsi'( �y+::"• SI" e�t��° 1, �M1d�Yt -"':�ti't�!1i�i'd'N�)'�k"Ci �i'�'�.G•"`'%�5�,�'�t�+a{�y"� iti6:li`.�:.�i'r�R3,'i�"''�d4, ivww�j.S iS..a.i ri- r . iw y .�� � .�� •vS x U.f i, 4 yZJry � '�q, l KYt�' (� DUG 1` ' J _ • J '� } :C _ k;P ..: ar(. xY:.;,°?. i.. °.• ! =: • 1 S .`.: �7 ' r. L 1�d •ia w.Six, d _l .�L: F DEPARTMENT OF HE1lTH -: ,. Division Of Environmental Hi�M Services T �... , . v FLOODING? TWO' COUNTY CENTER CARMEL, N Y 10512 (914) 225 3641 - .. f 1. •i -,r. -, rta•}, -cx :•x4✓ --. .v,. rot'. .. �:.`�^' 'pa. - _ - APPLICATION TO CONSTRUCT A.,WATER WELL Cr I WELL LOCATION WELL tGfi� tax w►w Nun�bER. , OWNER . NAME. • , GW' . AOORESS A ::. N %�a /i EWELL o i�o o us USE OF WELL IAA RESIDENTIAL 0 PUBLIC SUPPLY -0 - AIR /COND.IHEAT PUMP 0 ABANDONED _ 1 - primary 0 BUSINESS O FARM D TEST /OBSERVATION. 0 OTHER (specify) 2 - secondary 0INDUSTRIAL 0 INSTITUTIONAL' , 0 STAND -BY L7 r MOUNT OF-USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED _61-1 EST. OF DAILY USAGE o a. REASON FOR NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ;0 TEST /OBSERVATION ORILLING 0 gEPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL WELL TYPE DRILLED ❑ DRIVEN': (� DUG F [] GRAVEL [] OTHER N0: IS WELL SITE SUBJECT TO FLOODING? YES 1t• YIt;LL 1J WATER WELL CONTRACTOR-..,Name' IS PUBLIC.WATER'SUPPLY:AVAILABLE`T NAME OF. 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