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HomeMy WebLinkAbout3982DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.58 -1-48 BOX 31 LE', i � to ,, ; :�s ■ r LE', i � DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APFLICATIONwTU-- CONSTRI3CTi -A:: WATER WELL--;' /e rt ? 7PCHD PERMIT #U WELL LOCATION Stre dress V la t Tax Grid Number WELL OWNER N e �� (f ai� Address Public USE OF WELL 1 - primary 2- secondary A-RESIDENTIA 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O FARM O INSTITUTIONAL (3 AIR /COND /HEAT PUMP O ABANDONED O TEST /OBSERVATION "O OTHER (specify O STAND -BY O AMOUNT OF USE YIELD SOUGHT 6" gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__gal O REPLACE EXISTING SUPPLY O T 6$SEA Q ADDITIONAL SUPPLY ❑ NEW SUPPLY NEW DWELLING EEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING ' WELL TYPE ®DRILLED ® DRIVEN ODUG O GRAVEL. O 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 : /-"Y IS PUBLIC WATER SUPPLY AVAILABLE T eTE 7" YES x NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY - ;,:DISTANCE TO PROPERTY. FROM,NEAREST -WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET �n (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 thirt3! (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 o erations be contained on this property and in such a ma ner as not to degrade or otherw se ontaminate surface or groundwater. Date of Issue: ,v 1 19� 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 AIOPTH 1/00,901P - - - - L� It# /, / IVL C T ORO ET Q Qr NI I 7- PA &1EMFV T)WAY C— —A SAMAO' GUTTER -TV W Y OF PROPERTY L A kF P;IF r- 180.11• LK C.014c, A cr E, -TV W Y OF PROPERTY L A kF P;IF r- EA5r CHAIOV 61 I OOOK Ak 7-1 00 tL 3A 0 v (n ON3Hb3n 0— >4 -)3 W Or 'j IZ, C\J Cl QtU 6'.9 t7