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01036
DEPARTMENT Or HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
- "y- __' --'- -'APPLICATION - -TO" CONSTRUCT " °A - WATER' WELL`"'- --___,......
'�rlion,cf- PCHD PERMIT
WELL LOCATION
Street Address
s
To Village City Tax Grid Number
[• , - StS It? py
WELL OWNER
Name
Mailing Address i
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Private
V O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
t3 INSTITUTIONAL ❑ STAND -BY
O ABANDONED
[3 OTHER (specifq
O
AMOUNT OF USE
YIELD SOUGHT ,dr1 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE CO al
❑ REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION Q ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW DWELLING EN E ISTI3NG WEL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN
DDUG
GRAVEL
O
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�(1� _,.Address:
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
n —NA ❑ON SEPARATE SHEET
(date) (si nature)
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 suc a ma ner as not to degrade or otherwise contami surface or groundwater.
Date of Issue: 19 -
Date of Expira ion 19 Permit'Issuing Official
Permit is Non - Transferrable White.copg; HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller