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HomeMy WebLinkAbout4576DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -7 BOX 34 1'6 9-r 1.1 . f } •r L gr'i 04576 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO UNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 - APPI CATION TO CONSTRUCT `A WATER WELL PCHD PERMIT #� Df WELL LOCATION Street Address 0- bCV -1-9 To V llage City Tax D 3 u y� uct ec . G id Number WELL OWNER Name 7ps �' M it ' n iAddress g / rivate O Public USE WELL 1 primar 2- secondary O RESIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION d INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O ,. AMOUNT OF USE YIELD SOUGHT e gpm /# PEOPLE SERVED .� /EST. OF DAILY USAGE - gal REASON FOR DRILLING 0 NEW SUPPLY PROVIDE ADDITIONAL SUPPLY O REPLACE EXISTING SUPPLY DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING ' n WELL TYPE DRILLED DRIVEN ODUG GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: AZD Lot No. 03l r� �� WATER WELL CONTRACTOR: Name&/��n� Ancdr imian inc- Address: 4AP t n t�arl a..� IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: "—'— TOWN /VIL /CITY -DISTANCE TO "PROPERTY- FROM NEAREST 'WATER MAIN: ----� - " LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED �,p [O ON REAR OF THIS APPLICATION MON SEPARATE SHE T' t7��'1S 7 ` ^• (date) `�' ( gnature) 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. tDisinfect 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. Date of Issue: �`� �3 19 - -T 11— hermit Issuing Officia -- Date of Expiration : / 197_ Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller T� a