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DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Str,et Addrreess
I JQ
il�ltage City Tax Grid Number
own V^ U
aC/W v- r 7
WELL OWNER
Name . Mailing Address
GeI a aJ l Zic< V( CQ
rivate
0 Public
USE OF WELL
1 - primary
2- secondary
"RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
,� gpm /# PEOPLE SERVED S /EST. OF DAILY USAGE �``��i� gal,
REASON FOR
DRILLING
QNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY i.�[DEEPEN wEXISTING WELL
0 TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL
❑
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
Address :'M--# -r5�
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES No
NAME OF PUBLIC MATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION []ON SEPARATE SHEET ---� --
(date) �(sigX n to e� —�Jy�r l U "4 d'%!
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 s.lall:
1. Pump'the well until the water is clear.
2. Disinfect the well in accordance with the re uirem nts of the Putnam
County Health Department attached to this pe it. A
3. Submit 'a Well Completion Report on a form p vi by he 'u n m Cou
Health 'De artment.
Date of Issue: 19w
Date of Expiration: 19 �
ermit ssuing Official
Permit is Non - Transferrable White copy: H. D. File Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller