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BOX 11
01133
WELL LOCATION
WELL OWNER
DEPARTMENT OF HEALTH
Division of Environmental Health Services f/
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT $'
Street Address Town/Village/City Tax Grid Number
4 Ottawa Road Patterson, NY
Name Mailing Address O Private
Kevin Callaghan, 4 Ottawa Rd., Patterson,NY 12563 0 Public .
'USE OF WELL
RESIDENTIAL
O
PUBLIC SUPPLY
O AIR /COND /HEAT PUMP
D ABANDONED
1- .primary
0 BUSINESS
O
FARM
O TEST /OBSERVATION
O OTHER (specify
2- secondary
0 INDUSTRIAL
b
INSTITUTIONAL
O STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT
Jr
gpm /# PEOPLE
SERVED t /EST. OF
DAILY USAGE /00 Bal
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
EXISTING SUPPLY O TEST/ OBSERVATION LJ ADDITIONAL SUPPLY
®DRILLED DRIVEN ODUG O GRAVED 0 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 p - F_RPaI R gnnS_Tnn Address: J/.,p„tnamA -yP__ raw a +r�r N�
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
OON SEPARATE H E, CK
T oA
(date) s 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 such ner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: X
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