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HomeMy WebLinkAbout4106DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 83.73 -1 -28 BOX 31 I ro Wl MIA rjr- -1 i 0 I IN Ilk IN his 'L r .. - r am i 04106 1�� DEPARTMENT OF HEALTH. Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 �..; •APP•LICATION, =TG m 1 "; °WATER W _ ...:... , CJNS��RU @r A" WATER PCHD PF.RMTT A(1! WELL LOCATION Street /Addres}/ 4 #%0j /e w !G� Town /V llage City Tax �04 L-t e Grid Number WELL OWNER Nam So /! c �C Addre s ,p e le,, e .� er- T, le /l oz OPrivate O Public USE OF WELL 1 - primar 2- secondary XRESIDENTIAL O PUBLIC SUPPLY O AIR /COND/HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY O ABANDONED 0 OTHER (specify 0 AMOUNT OF .USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING NEW SUPPLY RREPLACE EXISTING O PROVIDE ADDITIONAL SUPPLY SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING We-27 +.ai2h r WELL ' TYPE ®DRILLED ❑DRIVEN ❑DUG ❑GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: o Lot No. WATER WELL CONTRACTOR: Name Address: .1 ,„ v IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO -J' ,,,,,, e, 04 NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DI.c,T�►.Nr� TO PROPER'T -Y FROM..- NEAREST -WA-TnR- X1 A1N -: .....- ... ....�... ..__.._ - n......._ .. _� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 7/ []ON REAR OF THIS APPLICATION ❑ ON S� TE HE ( ate) (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 th Putnam County Health Dep rt /ment. Date of Issue: V 19 A yd Date of Expiration: d/2,3 19 erm t I s, Z.;rngAOf'cia Permit is Non - Transferrable v?Y."�'•wrosrl3esi:.:i::' :,.Sgi•c++r, ie.Nw it �w.' ." ..�.iy, "::gj...•.R)ti' � v:�:iii - "R�i:r. piF•'� � .�....,:' w'. ... .. .. .... .K . _ _ ..'r, r; "Y ".i. �.. .:'+M:A...i:?�dv;5?a _ Y.... ;`�.'.� . .�."�'?� ..�'.`:.r ..',L•:'.; . -iC „4 �`�l?•3•��'.%�?., �..�!.r.:`y+�!h:•:� . ':i�V.jGJ:YC1.ui, ��� x:�• to [:v: \ -;;, ":i:..�::_s:CY..::.c._: .. ..:� DEPARTMENT OF WLTH Division Of Environmental Health Services TWO COUNTY CENTER — CARMEL, N.Y. -__105 (914) 225 -3641 APPLICATION TO ABANDON A WATER WELL PLEASE PRINT OR TYPE LOCATION $ih'cEf AUUHE;;' lie -�/4 / 4e".21, / (;,X GHIU NUA1d'tHWELL IU14N�YI�litr(� /�<C�r/ Z e WELL OWNER NAME. ` Z RESS.. . -e- - �i: �� 0 PUBLIC 1 G iC WELL TYPE ❑ DP.ILLED DRIVEN �I ^' � DcG ❑ GR�VEi, � OTS`R DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL ft. DATE MEASURED USE LL RESIDENTIAL ❑PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED - primar ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑OTHER (specify) 2 --secondary ❑ JNDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY WATER WELL Name: Address: CONTRACTOR: REASON FOR - ABANDONMENT: 1& DESCRIPTION OF WOiK TO BE PERFORMED: _ .a..... >._.._.a ..._� ,� a _.__.-- mss..__. __ _. _ -.. _. • - -,..� � - /'��� � - -•b .. -- ,.. . , • , 9 <.�... __ ._ .�:o. -o.. (date) (signature) PERMIT This permit to abandon one water well as set forth above is granted under.provisions - of Subpart 5 -2 of Part 5 of the New' York State Sanitary Code . and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. Date of Issue :�'v �j _ /OD "//tee )o 16"nIA I u Q., ALI r/cy,- k;seT 75" /10 A 'It Ice jWe oli- 7',qn I- irD ys I I