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BOX 10
DEPARTMENT OF HEALTH
Division of Environmental Health Services
*
'110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
.
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Srr et Address r� Town Villa a City Tax Grid Number
tl 2.e
r- n C . . ti sto
51, 7----4-
WELL OWNER
Name _ Ma,1ing A dress
. WPrivate
t'LS 1) n I fib'
0 Public
USE OF WELL
RESIDENTIAL OPUBLI.0 SUPPLY C)AIR /COND /HEAT PUMP
❑ABANDONED
1 — primary
Q BUSINESS 0 FARM O TEST /OBSERVATION
O OTHER (appel.;
2 — secondary
D INDUSTRIAL i31NSTITUTIONAL 0 STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT .a gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 500 Ba
REASON FOR
0 REI)LACE EXLSTI:NG SUPPLY ❑ TEST / OBSERVATION Cl ADDTTIONAL SUPPLY
DRILLING
p NEW SUPPLY NEW DWELLING) Ig DEEPEN EXISTING WELL
DETAILED
REASON FOR
#T�p� to/ 1,11 B
DRILLING
WELL TYPE
DRILLED DRIVEN
[]GRAVEL
DDUG
IS WELL SITE SUBJECT TO FLOODING? YES K NO
IF WELL IS LOCATED I.N A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR:. Name G� � ESlari Lieu C() Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES K NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
~
DISTANCE TO- S ROPE R Y -- FROM - NEAREST' -WATER hAI'N --.._-- __.--_._
WjAK*0N SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON SEPARATE SHEET
G� date) Q {signs ure)
c7 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 constructio_n__'_ -
the applicant shall: -
1. Pump the well until the water is clear..
2. ':aisinfect 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:
Date of Issue: 19_____�
Date of Expiration: 19
Permit is Non- Transferrable
Rev. 10/88
e� Issuing ca
Vfhite copy: H.D. File .
Yellow copy: Building IngxcWr
Pink Copy: .Owner
Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services
1°Z 0 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
-- APPI;ICATI 'ON- TO CONSTRUCT -A -WATER WELL
PCHD PERMIT
WELL LOCATION
Str et Addres
e.ytlV1
Town/Village/City Tax Grid Number
� rsa 0 s1- r7 -4,
WELL OWNER
Name -
a
Ma' ling A dxess
r w
cc "S an t6
PPrivate
O Public
USE OF WELL
1 - primary
2- 'secondary
RESIDENTIAL
® BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
0 ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED S /EST. OF DAILY USAGE 600 Sal
O REPLACE EXISTING SUPPLY' O TEST /OBSERVATION 13 ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING) DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
ODRIVEN
ODUG
OGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR:
ytb
NAME3F'LI`EWATER SUPPLY: TOWN /VIL /CITY
Ci & SOURCES OF CONTAMINATION
E)ON SEPARATE SHEET
c7.
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted Linder the
r 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,
Ii 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 De artment.
Date of Issue: 19�'..
j ermit ssuing is a
Date of Expiration: 19�
Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector
Mv. 10/88 Pink Copy: Owner
Orange copy: Well Driller