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HomeMy WebLinkAbout4299DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -1 -2 BOX 33 I I INS I I I I mm 01"ll Ll r 04299 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 _ e«.y:. .a f.. ��... .z.. .. •.. •...�_a ��'4p :. -. _�.: -.-v .... ♦ ..1 .. _ ..�i.♦ .-.. •...:i• - .�f�aa:...0 '.a" :... t ,. "CO .•:''y_•'"�.�. APPLICATION TO CONSTRUCT A WATER WELL PCHD •PERMIT # /� WELL LOCATION tre5t Address Town Vi, age City Tax Grid Number WELL OWNER Name �-_ Mailing C3. Address Private 2. DPublic USE OF WELL - primary 2- secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O FARM 0 INSTITUTIONAL O AIR /COND /HEAT PUMP O ABANDONED O TEST /OBSERVATION O OTHER (specify O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# REPLACE EXISTING SUPPLY O NEW SUPPLY NEW DWELLING) PFOPLE SERVED- /EST. OF DAILY USAGE_kal O TEST /OBSERVATION 13 ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING OM VXX_' v f ' .i'1 r / V C4 WELL TYPE DRILLED ODRIVEN ODUG OGRAVEL OOTHER 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 Q0`r%-N'j0L•n (3_( CSOn T(1C, Address : ]S()- ry , IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO -PROVERTY- FROM-NEAREST`WATER MAID :­ ' LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET s P C11 A 17 (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. we "il 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:. 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 riper • �� „O�lG�4G55� i�L2� a 113 i ..119 _ \ \ 1. 2.4 �� 3.3 } 110 _ if T•CPL .�_. ' g '11, ICI 3.1 x.! 1513 •4 CLL. f , Lll 23 � p°Sa .c c•L. � g 108 • w 4 ,�-J�•L/ 1 119 >a ,la n v I I `IIII III1 O 4 -E°OI .0 ^•l / JA / / ( D�II �� II 1 1 I' 2 2, •1= C.L. , 11.45 KC•L r � r '� � / /1 20 Ia .0 CAL �fl/ ( /y //JJ 12.5,5 •G / 111 \ , 7 o V r s' � / "'• �! �� /i ” 4 u o. ( Is.l' -�/ % � � � � / ✓ � (/, � /�/ /i�� G ✓ � I,�I� � �(/1 / /1VY I ,• I ° /�.. / 6 fa , �� is /` .y • ' /" NAfA ,ia ♦°.' 12 13 •:uaM •c,� I./ ••.Q `�/ ,/� �`' VP II• ' B :! °2e ,+to z.fi.,.c. y 17/� ii `, fC /' / t 2♦ �c.N .I 14.2. i wm'NL •sL+EY .c-.. :.�. 107 s.n A. _2 eac•L • � � ' 1 la» .0 OL •• •1pMlb 0� a [I IB / SOrax pOMK( PS rI =/ a ti 111 / /t/•°`� a • , �j�� 7 TOWN Lw .c. .GDUN {Y REYSION5 .I I1 2:4 cs•i. B /� y _1 Sia. � _i ua•c COUNTY _ �. • 12. ♦ �3• /// LJ•C '� end Lel Ka:19. 2.1 /� Lao•c w. �' BIOE1 T. Nal Uoa4 .O = 11• �• 14.1 I 1''t. / •• 1 •'I � v".. a flat. 1 now Na nqp YS •'I,•�'p . {u..c' [z -// '~ �` / %•' - —.Nr — can z,oil i�roa usatme .s 1053 &ono • ! Y.. % -2. : �' A �a • ESTfR r. - ✓ __ '-_ - __ ._.. V�� II ssL,�. x.2al4L.- L-r.�fx , - �• ....... - LEAP' ��'- 1•. LEGEND _ _ PRELIMINARY, ,1 RfVISKY6 SPECr.L DISTMT IAELTAtATION -7 — .r _ -' _ -_.• -- t racn 3:+.[2 1.2°J •• FOR'TA3: PUPPOSES ONLr -- .. ------ „ -- _ — _ TOWN OF PUTNAM VALLEY wm° �•�. _tay v:..T.aJ ...:J:w_•., ••:....+5s: .r.[•c.r .[ _'" PUTNA.Y GDUtR7.N.7. M i0 C vYD rOt °p,a£i•.i �', .; - :.('_..a.1 �_.:= .._= [.s.I.:r_ _-- s.nc• L - -. I � y ._. -�.� .. �_____ � � 4 Ii N[f,•fwnL wO[Otl[vr ��--- 1- N[E.av 2Lr_ -i _... -.. .0 a.r:. �,K :.r �.:•e:.::..[..r�- - _- �- _- .._� -- [a. - -_- � � it �. r_: �._ � _ ... .. .. -___ !:r 1 aa�AEiv ..n II:nET3, aL :.� .•= r:- •_ -.a... .. ___- _.I. ^. � ____� -- -� _� 1 __... ._._ __ VE i P :[a.! L:._u .: :.[:• .. rr v _..___ _ � [Y u sari+ �� - _ )))��' wrtzmn:.r.aa .•. «.: -. - _- :v,....' .....- _..... ..- .____.__..._._ -_____ -._ - PU i..a•A COUNTY. N.Y. n .. .... - I _. .. .[�.�r �... - -_• -_ _. � ,.. r .. I ( -t':. �Ir+.T.�. _.. ...):il :_e E. ra E. /. fM1F 5' Y r' �r r� 7I f