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HomeMy WebLinkAbout0339DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -38 BOX 4 . ' kr di ir'L i UL . Eo -: 1\0 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OL OUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 PPLICATION TO CONSTRUCT A WATER WELL PC_Hn PRRMTT &1 J1 17'11) WELL LOCATION Street Address 145 Cross Rd. Town/Village/City Patterson NY Tax Grid Number WELL OWNER Name Fred Schmidt Mailing Address 145. Cross Rd. Patterson NY QPrivate 0Public USE OF WELL 1 - primary 2- secondary 13 RESIDENTIAL O BUSINESS Q INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM p TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT gpm /4E PEOPLE SERVED /EST. 8 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION ❑ NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL OF DAILY USAGE_ gal Ll: ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING Ex i, S 11. U ' l S ins r G ,S WELL TYPE ®DRILLED ODRIVEN DDUG OGRAVE.L 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name P•F.Beal.&Sons,Inc. Address: POBoxB.,Breuster,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 ON SEPARATE SHEET (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 thirt3c (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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health 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 other contaminate'surface or groundwater. Date of Issue: l- 19 qd r-1g'1W' Date of Expiration jb 19'q 2.- Perm Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller