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01304
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01304
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL,.N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # W�
WELL LOCATION
Street Address Town/Village/City Tax -Grid Number
4 Parma Place Patterson, NY
WELL OWNER
Name Mailing Address
JARSharon Borchert, 4 Parma P1. ,Patterson,NY
OPrivate
OPublic
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�gal
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION M ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING []DEEPEN EXISTING ELL
REASON FOR
DRILLING
DETAILED
REASON FOR
'DRILLING
WELL TYPE
pDRILLED ODRIVEN
.ODUG GRAVEL.
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. Beal &Sons , Inc. Address :POBoxB, Brews ter, NY
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO- 'PROPERTY FROM NEAREST WATER -MAIN: - -
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON SEPARATE SHEET
(date) (signatu
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
thirti� (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 act:jn tb assure that
any and all water or waste products from such well drill •.:rati.GPs be, co, -atnc i on this
property and in such a manner as not to degrade or oth ntamillnc suillracP v• groundwater.
Date of Issue: 19
Date of Expiration 19'4? Pe it Issuing fficial
Permit is Non- Transferr ble White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
I