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01872
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01872
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
" APPLICATION " TO' CONSTAUCfi A''WATER 'WELL
PCHD PERMIT # r
IS WELL SITE SUBJECT TO FLOODING? YES _K NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR:
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _Y_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE IO - PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCU It SOURCES OF CONTAMINATION PROVIDED
[ffON SEPARATE SHEET
(da ) (signaturyl
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 such a manner as not to degrade or otherwise ate surface or groundwater.
Date of Issue• ��, *� 5 / ..�
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
Street Addr Town/Villa ge City Tax Grid Number
ss
WELL LOCATION
Pre N L CE`s ". :4�,f . �..
Name Mailing. Address
ffPrivate
WELL OWNER
o. �'�;r
%a 6 O Public
USE OF WELL
�/
® RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
1 - primary
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
2- secondary
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE (!() gal
UREPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION CI ADDITIONAL SUPPLY
REASON FOR
DRILLING
❑ NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
DETAILED
: S rtG We .11 jS ro to
p e ed �► F
REASON FOR
DRILLING
WELL TYPE
DRILLED DRIVEN ODUG 13 GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _K NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR:
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _Y_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE IO - PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCU It SOURCES OF CONTAMINATION PROVIDED
[ffON SEPARATE SHEET
(da ) (signaturyl
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 such a manner as not to degrade or otherwise ate surface or groundwater.
Date of Issue• ��, *� 5 / ..�
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
?, c � Acres
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