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BOX 10
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SAM co
TWO COUNTY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #��,y��-
WELL LOCATION
Stre d'dres
6 ct � Sa
Town 1 ge City Tax Grid Number
d 5MA Ok
WELL OWNER
_N e ,
�� Vt 1 -�SC.I
Mailing A dyes�j
j9e�tX�� K�� ��0�
Wrivate
C3 Public
USE OF WELL
1 - primary
2- secondary
13 RESIDENTIAL
O BUSINESS
O INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
M INSTITUTIONAL O STAND -BY
0 ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED S /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
EINEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY >DEEPEN!,2-EXI'STINQMWE'LL'1
0 TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
ft t
WELL TYPE
23DRILLED
DRIVEN
E]DUG
GRAVEL
® 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€�'TM 1'*" 1 "vim Address- bi
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
ON REAR OF THIS APPLICATION []ON SEPARATE SHEET
E 0--
(date) (signa ure)
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 ed t e Putnam Count
Health De tment. � 9 �
Date of Issue• Q
mi Issuing Official
Date of Expiration: P 1e2 19 - -�
Permit is Non - Transferrable �� copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
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