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DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
11�I'L`T'CATION -.TO ..CONSTRUCT' _A: WATER ' WEL1; ,.
PCHD PERMIT
WELL LOCATION
Street Address. Tow ' n V la e City Tax Grid Number Se a ".
WELL OWNER
Name Mailing Address Private
M G_ 0.y_UCX WVV.1L 4� , CL*4AAM My 111 6'� 0 Public
USE OF WELL
'1 - primary
2- secondary
It RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUAP Q ABANDONED
O BUSINESS O FARM 0 TEST /OBSERVATION O OTHER (specify,
O INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT +- gpm /# PEOPLE SERVED_'- /EST. OF DAILY USAGE S-60-gal,
REASON FOR
DRILLING
CINEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
WREPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
TOWN /VIL /CITY
WELL TYPE
,DISTANCE
®DRILLED
DRIVEN.
DUG
[)GRAVEL ® OTHER
SKETCH & SOURCES OF CONTAMINATION PROVIDED
�.IS WELL SITE SUBJECT TO FLOODING? YES _NO
WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
`WATER WELL' CONTRACTOR: Namao4QL AN&ress :1Qj1-55- CA111+Vto K) y
PERMIT
TO CONSTRUCT -' A HATER WELL
This permit to construct one water•well as set forth above is granited 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 pr d by the Putnam County
' Health Depa712- ment. �
Date of Issue: 19
Date of Expiration: 2 19— �'2__ ermit Issuing Official
Permit is Non - Transfer able copye H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
IS PUBLIC
WATER SUPPLY AVAILABLE TO SITE:
YES NO
'•':!;'NAME
OF PUBLIC
WATER SUPPLY:
TOWN /VIL /CITY
,DISTANCE
TO PROPERTY FROM NEAREST WATER MAINc
°A"
LOCATION
SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR'OF THIS APPLICATION
[P ON SEPARATE SHEET
(date)
(sign ture)
PERMIT
TO CONSTRUCT -' A HATER WELL
This permit to construct one water•well as set forth above is granited 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 pr d by the Putnam County
' Health Depa712- ment. �
Date of Issue: 19
Date of Expiration: 2 19— �'2__ ermit Issuing Official
Permit is Non - Transfer able copye H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
®y Artesian Well, G
No" R-t-e.--.,.
s.
Carmel N*,.Y. 105
(914) -225-3196
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