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HomeMy WebLinkAbout4362DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -11 BOX 33 04362 go M : ` me Flo I 9% r -� 04362 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 _ AP:i�LICA`PFCN TO tiCNS'ri7UCT' �i i�AZ'ER' �VELL PCHD PERMIT WELL LOCATION Street Address Town/Village/City Tax Grid Number 198 PEEKSKILL HOLLOW RD PUTNAM, VALLEY WELL OWNER Name Mailing Address QPrivate F12IE0 i AiV 198 PEEKSKILL i1OLLO�! ?0 PUTN.V�i VALLEY- DPublic USE OF WELL AX_C *Xi y 2 - secondary 0 RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY ❑AIR /COND /HEAT PUMP 0 ABANDONED O FARM O TEST /OBSERVATION Q OTHER (specify O INSTITUTIONAL O STAND -BY O r,,uF te-lmitqF7-� AMOUNT OF USE YIELD SOUGHT 10 gpm /4i PEOPLE SERVED NONE /EST. OF DAILY USAGE 70al E3 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION C(ADDITIONAL SUPPLY p NEW SUPPLY NEW DWELLING Li DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING 00 NOT i ITSH TO USE EXISTING WELL TO ZVATER GREENHOUSES. E IST �'VELL IS TO FAP F?O i GREENHOUSES WELL TYPE ©DRILLED DDRIVEN C]DUG GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: N/A Lot No. WATER WELL CONTRACTOR: Name FRICKSON &BOTHERS Address: COLD SP1,.ING, IVY IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: itl /A TOWN /VIL /CITY DISTANCE .TO. PROPERTY _FROM NEAREST WATER'-MAIN:,- _ LOCATION SKETCH & SOURCES OF CONTAMINATION < Iq 95 O ON SEPARATE SHEET (date) PROVIDED i (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 thirt7 (30) days of the completion of water well construction, the applicant shall: v 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 of rw'se contam' ate surface or groundwater. Date of Issue: 19 lu 1 Date of Expiration r 19_ Permit Issuing Official ?ermit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller