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BOX 12
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01201
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
_._- APPhICA1 ION "TO` -CONSTRUCT._'N':WATER-. WELL
PCHD PERMIT #
WELL LOCATION
reet Ad. res
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White copy:
wn Village Cit Tax Grid Number
-M
WELL OWNER
Nam
Mailin Address rivate
O Public
USE OF WELL
1 primary
- secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP ❑ ABANDONED
O FARM O TEST /OBSERVATION p OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT__,14�_gpm /#
JKREPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING)
PEOPLE SERVED /EST. OF DAILY USAGE_____gal
❑ TEST/ OBSERVATION 12-ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
A% A
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AU 14., -
WELL TYPE
DRILLED
DRIVEN
[]DUG
C]
GRAVE ER
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 Address: 'I v
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES NO
NAME OF PUBLIC WATER tUPPLY: %✓1 �• TOWN /VIL /CITY
DISTANCE .TO PROPERTY'. FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(date) (signature
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
thirt;• (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 otherwisec.contamina s rface or groundwater.
Date of Issue: 19_
Date of Expiration 19 0T7 Permit Issuing Official
Permit
is Non - Transferrable
White copy:
HD File
Pink copy: Owner
3/89
-5 "
Yellow copy:
i
Bldg. Insp.
Orange copy: Well Driller
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