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BOX 17
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01907
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914).1278 -6130
'=AP-.B:LI CAT ION >. TO CONSTRUCT =A .WATER WELL ---....,'
x_ PCHD PERMIT
WELL LOCATION
Street Address
. own Villa a City
Tax Grid Number
WELL OWNER
Name
Mailing Address
OrPrivate
,O Public
USE OF WELL
1 - primary
2- secondary
eRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0PUBLIC'SUPPLY OAIR /COND /HEAT PUMP 0ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specifq
b iNSTITUTtONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE SERVED /EST.
OF DAILY USAGE
REASON FOR
DRILLING
J9 REPLACE EXISTING SUPPLY..: ;. Q TEST/ OBSERVATION
O NEW SUPPLY NEW DWELLINO .13 DEEPEN EXISTING WELL
Gl ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DDRIVEDI
DUG
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES No
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAXE' OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name OS +
.IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES No
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
r
DISTANCE TO PROPERTY FROM NEAREST -WATER MAIN:—_
LOCATION SKETCHJ6 SOURCES OF CONTAMINATION .•P.$OVIDED
ON SEPARATE SHEET oz.�
a -9 -961
(date) " ' (signs ure)
9 a
PERMIT TO CONSTCT A WATER WELL
This permit to construct one water well as seZi'forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State4Sanitary Code, and provided that within
thirty (30) days of the completion of water Vel-i•construction, the applicant shall:
1. Pump the well until the water is clear.;
2. Disinfect the well.in accordance with`1he requirements of the Putnam County Health
Department attached to this permit,,.: w
3. Submit a Well Completion Report.on.-4`f9rm provided by the Putnam County Health Department.
During all well drilling operations, the-ApRlicant 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 contamin surface or groundwater.
Date of Issue: 199 _r-
�—
Date of Expiration 19!'te Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
,?s
Boyd Artesian Well Co., Inc.
h .z No. 5 -Rte. -5,27.
Carmel, N.Y.10512
(914) 225,3196
ABILITY
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