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01687
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01687
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130 /
APPLICATION TO CONSTRUCT A WATER WELL
WELL LOCATION
Stree Addr ss
PQ
own illa e.City Tax Grid Number
oti _ .3!�, - '1 _ 36 j
WELL OWNER
Pa�rtc�
Nam Mailil}9 Add ess
G't a► -� B, �I� 4� By d." A. 10,;7Jj
Private
13 Public
SE OF WELL
1 - primary
- secondary
.RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
BUSINESS O FARM ❑ TEST /OBSERVATION
0 INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING
PEOPLE SERVED.. S /EST. OF DAILY USAGE L0L0gal
O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
d r v 1, v l a
Q K
If
WELL TYPE
ODRIL L ED
DRIVEN
DDUG O GRAVEL
O OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L�-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 4-- o - c-, Je
Lot No-. �q
WATER WELL CONTRACTOR: Name ti 4 Address: Q o
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES (ENO
NANE OF PUBLIC WATER SUPPLY: /9- TOWN /VIL /CITY �-
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �-
LOCATION SKET H & SOURCESIOF CONTAMINATION PROVIDED
PkON 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 such a manner as not to degrade or otherwise contapinate surface or groundwater.
Date of Issue: Z2 _ i 19 V'3
Date of Expiration 19 Permit Issuing Off al
Permit is Non - Transferrable White copy: HD File Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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