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Home My WebLink About0462DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.07 -1 -58 BOX 6 Am -5 FL Fri UAL' 00271 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL V PCHD PERMIT '9`S WELL LOCATION Street' Address A, k Qk C To Village City _ Tax Grid Number /� r WELL OWNER. Name Mailing Address G C fJ� `s' A) 4- Sc SC /C- OPrivate 0 Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_,gal REPLACE EXISTING SUPPLY O TEST/ OBSERVATION CIADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING) O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING Lo S vC= 44i �141 WELL TYPE GRILLED DRIVEN DDUG C]GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name HJ, ,ilr-- al � if C? V- W/ Address :/f- /i %'i�%% L�i(°S�JZ!: AZA/ IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __y _NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: d LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET �t (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 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 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 suc anner as not to degrade or otherwise - ntafinate sur r groundwater. Date of Issue: / /?�� 19 / Date of Expiration 19 - -�=— Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller V PUTIVAM °COUNTY HEALTH DEPT. 4', Geneva Road (914) 278.6130- B"- ... .. NY 10509 I7 9 ` j s: w Date' 1 Received of � " i The Sum Of-- a Doll rs � For 16Aul -- ,� 0 I SUBDIVISION PLAT PREPARED FOR I NCIS A . 8r CASSANDRA ...S ? EP =; .`r5!rM SI TUATE 'IN : �j TOWN OF PATTERSON � . r- Ml , -r n i n A.4 S T/I T f: * OF NEW YORK L..OY I 5 b1 000 5Q. 2� � ..' 1 S. 3 ° 34', 2784 C Z.IIB i y �q8 � Z IBP F. M. 1861A, LOT 1A NOI - 00 -OOW 125.52, P p %S 25.10 _ 0 h to an r. ry `, /F CriSON 's Certified 'c- Francis A. d Cassandra, Schepperle Commonweoltn Mortgage Co. Statewide Abstract Corp. for policy No. SA 80035 - P R /9, 01 3 story O dwelling O — In _ M m F. M. 1861 A I LOT IB p '? a AREA- 1.252 r acres ' � � O I a \ Po!e 150.00 pole S02 -28-02 E CORNWALL HILL ROAD SURVEY PREPARED FOR FRANCIS A. 8r CASSANDRA SCHEPPERLE SITUATE IN TOWN OF. PATTERSON . COUNTY OF PUTNAM STATE OF NEW YORK SCALE I" = 50' APRIL 22, 1987 JAMES K. DEVINE LAND SURVEYOR 1 9 4 CHAS. COLMAN BLVD. UNAUTHORIZED ALTEM110t10R ADDmoN TO PAWL I NG , NEW YORK * TNIS SURVEY MAP IS A VIOIATION OF SECTION 12564 7209 W OF THE NO MK 64111 EDUCATION a LAX a Cepiss o1 this eartm eup ed 1taalfq th Lead 4904 8—yaa tmb-W seal ebatl eat he oommaraa LANl7 `' bas alq taw coq. 85008- IB �1 "Guarantees or Certifirationa indicated harem. siynNy that this survey was prepared In acwrdanca with the existing Code of PmCUC0 fe land Surveys adopted by the New York State AssoclaL'on of Professional land Surveyors. Said 9MMAL6 a of unifiCatlans Shall run only to the person fa whom the survey IS prepared, and on his behalf to the title company, governmental egancy and lending Institution listed Person, and to the assignees of that landing Institution. Guarantees w anincetions are Felt transferable to additional Insti- Dalons or Subsequent comers.,, DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL V/ w -yo.�y PCHD PERMIT # WELL LOCATION /Q Street Add �ss� T wn .Vil lage City Tax Grid Number WELL OWNER NameMailing Address �' 3 Private O Public c1SE WELL primary-) 2- secondary SIDENTIAL O PUBLIC SUPPLY BUSINESS O FARM 0 INDUSTRIAL U INSTITUTIONAL O AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT__5� gpm /# PEOPLE SERVED3—S /EST. OF DAILY USAGE C�%Sal EP LACE EXISTING SUPPLY O TEST/ OBSERVATION. LIADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DDUG C]GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name y Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ,r/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:- LOCATION SKETCH & S0UR2ES...OF" CONTAMINATION ��--SEPARATE SHEET (date) PROVIDED _jej�� -�f (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 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 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 otherwise contaminate surface or groundwater. Date of Issue: 19 15 Date of ExpY59ion 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller