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01905
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION-. -T•O•: CONSTRUC.T_.A WATER WELL_.%
PCHD PERMIT #
%37
137--
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
WELL OWNER
Name �Aiffng Address
req or .r
Q. �
Wrivate
jg OPublic
USE OF WELL
1 - primary
2- secondary
JLRESIDE TIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT _gpm /# PEOPLE SERVED 6- OF DAILY USAGE ,,5_0D $al
REASON FOR
DRILLING
Q- REPLACE EXISTING SUPPLY O TEST/ OBSERVATION M- ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLINQ 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
ue&_ . e4cwNsw h Ply to
-
WELL TYPE
.DRILLED
EIDRIVEN
DDUG
EIGRAVEL
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:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES PL 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) (signatur )
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 -y (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 man V r as not to deg de or otherwise contaminate surface or groundwater.
Date of Issue:
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
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