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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL q
PCHD PERMIT
WELL LOCATION
Street AAdress
f - 1 >
Tom
a ty Tax Grid Number
WELL OWNER
ame Mailing Address
1�,,, !
)WPrivate
O Public
USE OF WELL
1 - primary
2- secondary
JMRESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY
O FARM
M INSTITUTIONAL
O AIR /COND /HEA PUMP O ABANDONED
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED -- -/EST. OF DAILY USAGE S5,.) al
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 'ADDITIONAL SUPPLY.
O NEW SUPPLY NEW DWELLING1 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
QDRILLED
DRIVEN
[]DUG 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
Address: 52,
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 0 v ,�
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DIST'A'NCE- T^ - PROPERTY FROM NEAREST - -WATER MAIN.:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON 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
thirty (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�
Date of Expir ion 19 - -� Permit Issuing Official
Permit is Non - Transferrable .��- -� -White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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"► P'4i9CEL SHO.i✓N DESIGNATED AS LOTS <B- 51 TN.9!/ .Sff0�4N ON .4 f1�4P
L ENTITLED, %'SAP B1 3� T�T�4� j CLO O LSO B � 6 A 4� B 75T TO
t0 �y ypyy LOTS B
8- 3441 INCL . , DATED /W V,C5� 17. �9�f '4N0 FILED IN T�`/E Pl/TNf1f1 COUNTY CLE
OFFICE ON wlWsT 19, 19 1 AS FILED �1AP /149�i