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00926
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # /U "!
WELL LOCATION
Street Address
a� �a � � � �Q
Town Vil
�Pa
ge_/City
Tax Grid Number
WELL OWNER
}tae ing
t-1 6 P -El Y"V10 l� • �/
Addres
t �
a C-1'
Private
tf 4" K O Public
USE OF WELL
1 - primary
2- secondary
Qi RESIDENTIAL O PUBLIC SUPPLY O AIR/ COND /HEAT PUMP Ge ANDONED
0 BUSINESS O FARM O TEST /OBSERVATION ❑ OTHER (specify,
O INDUSTRIAL 0 INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT s gpm /#
PEOPLE SERVED 6'
/EST. OF DAILY USAG&570D Sal
REASON FOR
DRILLING
® REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLINGI
O TEST /OBSERVATION CIADDITIONAL SUPPLY
O DEEPEN EXISTING WE L
DETAILED
REASON FOR
DRILLING
'
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL. 0
OTHER
LOCATION SKET O& SOURCES OF CONTAMINATION PROVIDED
N SEPARATE SHEET
I -r-g -3
(date) 9 (� (sign ture)
= ij ' :j 1
PERMIT TO CO VCT A WATER WELL
This permit to construct @` rth above is granted under the provisions
of Subpart 5 -2 of Part 5 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: 152
� 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