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BOX 13
01348
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 # ��
WELL LOCATION
reet Address,-,
� �
To Vi a e City Tax Grid Number
WELL OWNER
Ne
Mail in Add ess
�
Private
O Public
USE OF WELL
1 - primary
2- secondary
"RESIDENTIAL
D BUSINESS
D INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
U INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE o e gal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION - GI: ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING) VVEEPEN EXISTING WELL
REASON FOR
,,DRILLING
DETAILED
,REASON FOR
DRILLING
a�/ Gvv �✓
WELL TYPE
DRILLED
ODRIVEN
®DUG
0GRAVEI,
[:]OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _�C NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name c Address: fly �oS79
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 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 suc a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19_3
4;01_ Date of Expiration 19_ 7 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller