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BOX 11
01163
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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 #w 65-e
WELL LOCATION
Street Address
32-
Town/Village/City Tax Grid Number
Dr. Arelds er IV y
WELL OWNER
Name
F} ia..n Lee
Mailing Ad ress
32. /-Aid br 6r&--,s'fe,- NY /CZ7
$Private
0 Public
USE OF WELL
1 - primary,-
2- secondary
O RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
M INSTITUTIONAL O STAND -BY
0 ABANDONED
OTHER (specify
AMOUNT OF USE
YIELD SOUGHT_ _gpm /# PEOPLE SERVED 5- /EST. OF DAILY USAGE gal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION CIADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
[]DUG
O
GRAVEL
O OTHER
IS WELL SITE SUBJECT TO FLOODING? YES . X, NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
''d' Lot No. �� p
WATER WELL CONTRACTOR: Name �-/ 1 PAX JV �'�1 / C° Address: 4f"
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE -TO PROPERTY . FROM NELRE. ST - WATER - MAIN: ...._ .... _..._. _...._ ..... .
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET I �n� &
�1 _ZILA, „(
(date!) (sig ature) tv
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
Department attached to this permit.
3. Submit a Well Completion Report on.a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
During all well drilling operations, the applicant
any and all water or waste products from such wel l
property and in such a ma per as not to degrade o
shall to appropriate action to assure that
drill id o erations be contained on this
r'other "* e ¢ontaminapA^Q surface or groundwater.
Date of Issue. 1411419
Date of Expiration 19 Permit Is uing Official
Permit is Non - Transferrable White 'copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller