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HomeMy WebLinkAbout0076DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.16 -1 -1.2 & 1.3 BOX 1 00076 11 Ir , Pr r i 161m IL ,. l 00076 DEPARTMENT OF HEALTH Division of '.Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225-3641 �e APPLICATIO9 TO CONSTRUCT A WATER WELL D(T-Tn DVDMTT a %9 )_ 4q 40 WELL LOCATION Street Address Town /gee 6i�• Tax Grid Number Lisa Court Patterson 1 -4 =2.22 WELL OWNER Name Jim Grundman Mailing Address Mahopac, 469 Watermelon Hill Road, 10541 NY ®Private C3 Public USE OF WELL © - primary 2- secondary ® RESIDENTIAL O BUSINESS 13 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify Q AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 4 /EST. OF DAILY USAGE 60 0 gal REASON FOR DRILLING UINEW SUPPLY O PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING Lot to be residentially developed Date of Issue: 19� Date of Expiration:' `o 19 WELL TYPE DDRILLED DRIVEN E]DUG []GRAVEL ® OTHER 2/87 IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Jim Grundman / Michael Reiser Subdivision Lot No. 2 WATER WELL CONTRACTOR: Name Hyatt & Sons Address: Patterson, NY IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 7! SV9 D O ON REAR OF THIS APPLICATION X0 EPARATE SHEET (date) sig ure) Philip A. Leger -- JRFA 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 prov' d by the Putnam County Health Dep rtment. Date of Issue: 19� Date of Expiration:' `o 19 y Refmit ssuing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - ,,CARMEL, N.Y. 10512 (914) r 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Address Lisa Court Town Tax Grid Number Patterson 1 -4 -2.23 WELL OWNER Name Jim Grundman Mailing Address, Mahopac, 469 Watermelon Hill Road 10541 NY ®Private O Public q1jSEE OF WELL - primary - secondary ® RESIDENTIAL (3 BUSINESS 13 INDUSTRIAL [] PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify Q AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED . 4 /EST. OF DAILY USAGE 600 gal REASON FOR DRILLING @NEW SUPPLY []REPLACE EXISTING SUPPLY []PROVIDE ADDITIONAL SUPPLY 0DEEPEN EXISTING WELL ©TEST /OBSERVATION DETAILED REASON FOR DRILLING Lot to be residentially developed WELL TYPE XODRILLED DRIVEN []DUG OGRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:' Jim Grundman/ Michael Reiser Subdivision Lot No. 3 WATER WELL CONTRACTOR: Name Hyatt & Song Address: pattersnn IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION Elm S PARATE SHEET -26Z /19 10 _ gn u (date) re) Philip A. Lecter -- JRFA 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 provi by the Putnam County Health Department. Date of Issue:_Ihi 19 Date of Expiration: 19 1 a it Issuing fficial Permit is Non- Transferra le White copy: H.D. File Yellow copy:. Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller 'Na \ Ell 40 vw.A.Ls CSL WrTmim 2 ..'ISOMMEMME 7- a t..9 .100 CON ANT REAL- 'Y - low 1�, f t. t.1aT M SL v I �..D'.s f= ►t—t. Cj,�fZTg1N t7@AiN k. pC.9a, D6PTH . %*L_.. . 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