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HomeMy WebLinkAbout0525DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 15. -1-47 BOX 6 00525 ,i L } ' Ir k� ' ��' a 12 00525 DEPARTMENT OF HEALTH Division of Environmental Health Services Mary Bridget 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMITl.✓�o�+�' WELL LOCATION Street Address Quaker Lane, Town/Village/City Tax Grid Number Patterson, NY 15. -1 -47 WELL OWNER Name Klinkenbergh, Mailing Address ®Private Frans, Quaker Lane, Patterson, NY OPublic USE OF WELL 1 - primary 2- secondary ® RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�al ® REPLACE EXISTING SUPPLY O TEST/ OBSERVATION , 12-ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING 13 DEEPEN . E ISTING WELL - REASON FOR DRILLING DETAILED REASON FOR DRILLING IF Has no potable water. Shallow well contaminated A ,✓ s W va'% -✓ �- ° S J WELL TYPE DRILLED O DRIVEN ODUG C3 GRAVED OTHER 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 P.F. Bea 1 & Sons, Inc. Address: 4 Putnam Ave., Brewster, NY 1050 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 6 SOURCES OF CONTAMINATION PROVIDED Q ON SEPARATE SHEET 6/5/97 date) ') ''JJ ( gnature) Vol ry ^�2iG��bar3 LAP') Pe L. Beal 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 h any and-all water or waste products from such well drill property and in such manner as not to degrade or oth Date of Issue: 19 �i Date of Expiration 19 r Perm t Permit is Non - Transferrable White copy: 3/89 Yellow copy take appropriate action to assure t at klrg'o erations be contained on this e ontamina surface or groundwater. Issuing Official HD File Pink copy: Owner Bldg. Insp. Orange copy: Well Driller i f. i i R 0 ebb •` 5�,� u r SApu-ow wdl SIN 2 VnaM I S NAME SITE LOCATI% PUTNAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES /� - %/ -0/ PHONE 2'? ri - MAILING ADDRESS PERSON INTERVIEWED PCHD Camplaint # Name & Relationship U.e, owner,tenant, etc.) DATE TYPE FACILITY PHONE T-3d -39 S REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. �r "el - .. / n : $ 4 J J.�. Proposal approved s Siqnature & Title /00 40"5e- Proposal Disapproved rovosal amroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywalls surrounded by one foot + gravel). e. Installer's name and number. (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner r po agent of owner agree to the above conditions. SIGNATURE TITLE DATE �r 3-CM: * ite (FM); Yell w (Town ED; Pink (.Aftlioant)