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HomeMy WebLinkAbout4375DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.-2-30 BOX 33 04375 .` 6 ' ys 3' I I f r .I 04375 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # 0.-. yo.- g 1,- WELL LOCATION S=9kI&L Address Town Village City Tax Grid Number 0 iP - A-3o- WELL OWNER Name lA/ Mailing Address ► f WPrivate S i_z a /�a t. Public USE OF WELL 1 - primary 2 - secondary OrRESIDENTIAL „ 0 BUSINESS ® INDUSTRIAL ® PUBLIC SUPPLY 0 FARM U INSTITUTIONAL ��� Q AIR /COND /HEAT PUMP F7 ABANDONED O TEST /OBSERVATION O OTHER (specify, O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED _-f' /EST. OF -DAILY USAGE al ArREPLACE EXISTING SUPPLY O TEST /OBSERVATION' D. ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG aGRAVEL • OTHER IS WELL SITE SUBJECT TO FLOODING? YES ){ NO IF WELL -IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. p q E . M -4eN sr. WATER WELL CONTRACTOR: Name 6& / �}a,�,p s'y� ) , s-� � . Address : �� � as A1.4 IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >( NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY bI§TANCE TO 'PROPER'11 FROM NEAREST WATER MAIN:` " LOCATION SKETCWON SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET 'j 1919.2 (d to ) Vignature) 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: IYA1 /J 19� Date of Expiration f'1 / 19 Permit is Non - Transferrable Whi e 3/89 Yel o' shall take appropriate action to assure that drilling operations be contained on this Iherwise contaminate surface or groundwater. 7cppy: Issuing Official y: HD File Pink copy: Owner Bldg. Insp. Orange copy: Well Driller t�LL u� 1 •'` S as. 1. r!� r11��0 . , �'�,6� ,, � 31 � •+ �l G� iii �� e '� �Jv ��`�� a'v �� ' AO Q*4, �lia I� "Eq7 ask u It At�rc Pw 100 i41 z t � 1 c i'1<lir 9. I' 1 � ,� p5�s 4•�-. X, ',; i,Y\ a•t'''ta `S, i s fiw , yut �.srA "t t n H � s r t {.�} 3 �,c f{ i{F-�'{` t • �.1^t � W' �1,�"p�r � t ' 3 ' % Vi!' Y'fl ,�' '� h� ,�• �,Y'�'"r01—, ? r'S. ` '+ ty .7 , �Sj, �,e�.0 �4 } �� t � ,t ^rr � f �� n a 4•�� v � }{ �'� �`^ , '�' eat t 1�;�'t + 'nE �`�.lt r�� Y -��•� ;��f`" �� }'r � h�t�+rE'�,lxa �i>r } t ` sUxfM� vaz` y ct r ;cs ff7� �y�`o a: � � � ri,�^` 4 ".'� ,�i�� e1v 't�,� t .s fi• i �,�+� '��'� �+ ... � s r '• �h} y, aG� \ii t� n�e ft L`— t� � f� 1{�n. �y � +fU' 'sit ut }xJ r 2 ,u,e �f' .. K ^,�+ - 's �1, iti(�4 ,l to •�q S. ♦� a4'� 'i' ! � _ ; r .. t � ^S• ,'�� rr t -� v t'k�� N €',��'. n 0. ' }r�u K�Jd µ r 't tt L yy ... ri4» 'x..'��'v4q; , \tti A.'t^P � atlt�i��� "��`'>!•ei r' ! "7'iatlht.��.��c{�, •'lun �' ,4l�t:jl.aii. 2 =C ft,7- x- tom•,+..:._ ,hvt ..L ut f �f'> -4 .. . ..... i 1�4' A• l e0 A1 �?� y4 Y y,/ z � ��s� L� t i.,; � \ f S•,• �� �r it,�'��-,���' �,����aR•{ �1�'. Q ?� ��,F' d 5 f ' +a N �� *,ie'k�"� I1�''t�y4t J' x'{` „'N i'FSIt L, > '. a :: I 4 r..,. \ -w `� 9 mot• s .z `” r I f - .f ,� .:,� #"S t t•r. -n. ; � t 'Ya'ii {k�`sxh�` -� i •i.Y b" Y y n1 ` ,S ,� at .. �!�/�/P %Iy�i, ,%»EieL 7 t ! 4• ' '�t r�� -.�y ,�� � , , � P01.i.'�.l1 %O.�/ , O,V� y A' IY��'°,8E - �,v0 /G' a T.�� .. ' ' ' • o�.x�+'� •�%�v.' rte' � a9+ `i/ E.G.'C�'rL4 CNif�/.�°.C/T✓" BBL "GBH! G.e'4 L7iE, %f �A.t! y �.c/ol' ./NO�Yit/ h/.[T. b.. ._ ., n!✓t:.:Y_ti�k!a _ . .... _ .,. ... . _. __,.. .. .. .i -,. .. ;- •atrt...'�_', .. 1 fa t.s .r'ze 1�',