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HomeMy WebLinkAbout4293DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.83 -1 -35 BOX 32 04293 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 278 -6130 , APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address 7 r"+ P Town Village City f v VO-1I Tax Grid Number g3 . ' -- / -3S WELL OWNER Name Mailing Address C t8O;x /2 P1jh/Am I/6./ / Private /V `/ OPublic USE OF WELL 1 - primary 2 - secondary Q(RESIDENTIAL 0 BUSINESS D INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify O INSTITUTIONAL ❑ STAND -BY U AMOUNT OF USE YIELD SOUGHT S gpm /# PEOPLE SERVED 5 /EST. OF DAILY USAGE al REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY ❑ EST /OBSERVATION 13 ADDITIONAL SUPPLY ❑ NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DDUG OGRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Laze Lot No. WATER WELL CONTRACTOR: Name 1 Rrt'ieSic fl We Al CO Address ,52 aa Mel IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO SUmM�' "rz-4er NAME OF PUBLIC WATER SUPPLY: Lok-e- ReeK_5k TOWN /VIL /CITY DISTANCE TO PROPERTY FROMTNEAREST -WATEi _MkTN:" LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON 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 any and all water or waste products from such well property and in such a manner as not to degrade or Date of Issue: ., " -12 Zee._3 19_L'_�_ Date of Expiration,42��Z?_ -Z___. 19 e!:9 Permit is Non - Transferrable White 3/89 Yelloi shall take appropriate action to assure that drilling operations be contained on this otherwise con tami.nat ur-fac-e­er_ roundwater. .ermit ssuing Official copy: HD File Pink copy: Owner a copy: Bldg. Insp. Orange copy: Well Driller