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BOX 10
01013
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01013
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��S�O
WELL LOCATION
Street Address Town Village City
Tax Grid Number
zs" -y - - 3
WELL OWNER
Name MaJ. inq Address
L11wr e C/ i G/e—
0Private
O Public
USE OF WELL
I - primary
2 - secondary
O RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O BUSINESS O FARM Q TEST /OBSERVATION p OTHER (specify
0 INDUSTRIAL M INSTITUTIONAL ❑ STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED__ /EST.
OF DAILY USAGE. L6 Sal
REASON FOR
.DRILLING
L] REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION
0 NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
D: ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
�p �y P
WELL TYPE
MIDRALED
DRIVEN
OGRAVEL
a
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 ( Rr4 jtG tj WeA Co Address:-
ddress : 52 GnA,?I' d /jy /ds- /z
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY..FROM NEAREST WA.TER,.MAIN:.
LOCATION SKETCH& SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
/�/7,17
( ate) si natid e)
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 surdace or groundwater.
Date of Issue: /�� 2!a 19 1C�
Date of Expiration ,� / ' 1 Q Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller