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01289
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 PERMI`1' &I-4 —).
WEL LOCATION
Street Address
6'Q k+ZZD
Town/Village/City Tax
'k-0, At ✓vA A A x,c P
Grid Number
5O
WELL OWNER
Name
�CA/ &/ S 1,00
Address
J- F
'Private
❑ Public
USE OF WELL
1 - primary
2 - secondary
.'RESIDENTIAL
0 BUSINESS
❑ INDUSTRIAL
❑ PUBLIC SUPPLY C) AIR /COND /HEAT PUMP
O FARM ❑ TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
D ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT s gpm/ # PEOPLE SERVED /EST . OF DAILY USAGE _5 OQgal
REASON FOR
DRILLING
MZNEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY
REPLACE EXISTING SUPPLY ® DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN E]DUG 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 R. D. 5 -Route 52 dXS-3 /?wAddress:
arme ``,,
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
_ ❑ ON REAR OF THIS APPLICATION EPA E S ET
(date) %x �' t��':7o2tit -�� - -� —/ (s'gna 6u re
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:
Date
Date
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 D partment. _% -
of Issue: 19
of Expiration: 19v--� --- ermit ssuing Official
Permit is Non-Transferrable
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