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01636
DEPARTMENT OF HEALTH
Division of Environmental Health Services
d�. 4 Geneva Road, Brewster, New York 10509
�¢ (914) 278 -6130
" APPLICATION` TO " CONSTRUCT A WATER WELL p
PCHD PERMIT #1dL�L[
WELL LOCATION
Street Address Town /y llage City Tax Grid Number
WELL OWNER
Name M dng i Addres
L Qc N�f-
11 QQ
`V11fLQW� ,( fit
Wrivate
13 Publ ic
USE OF WELL
1 - primary
2- secondary
QRESIDENTIAL O PUBLIC SUPPLY
0 BUSINESS O FARM
O INDUSTRIAL U INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
0 OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT_ 7 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE SbJ gal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION LZ ADDITIONAL SUPPLY
13 NEW SUPPLY NEW DWELLING �DEEPEN:EXISTTN WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
:wt!l Co W
t t
WELL TYPE
%DRILLED
O
DRIVEN
DDUG
O
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_
d� r�2Sla vi �li Q � Address : �� S7
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES K NO -3 ITT
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
-- _DISTANCE�TO- PROPERTY FROM- NEAREST- WATER -MAIN: _. _......=-_---- .....;.,_._�...a__.._.__._..... _. ....... _ _.. _.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET
(date) (signat 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:
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 such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19 _p _
Date of Expiration 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