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01943
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL -- p �.�
PCHD PERMIT #
WELL LOCATION
Street. Address
Town/Village/City Tax
Grid Number
d
ON
WELL OWNER
Name
\ �Am
'
Mailing Addres$
�b 77'sOtJ
Private
M N
L iOn7 Zia
0Public
UE OF WELL
11RESIDENTIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 ABANDONED
1 primary
USINESS
O FARM p TEST /OBSERVATION
O OTHER (specify
2- secondary
0 INDUSTRIAL
O INSTITUTIONAL O STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGZ506 gal
REASON FOR
qREPLACE EXISTING SUPPLY EST /OBSERVATION M ADDITIONAL SUPPLY
DRILLING
O NEW SUPPLY NEW DWELLING) f&� EPEN EXISTING WELL
DETAILED
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REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN ODUG
OGRAVEL
O
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 ► I- a C�Ctls Address: M,& k ,
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
_. DISTANCE -TO-- PROPERTY- -FROM NEAREST •WATER MAIN;
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON SEPARATE SHEET
/a 3 2 g - Z�22
(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
thirt3- (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 oniaminate surface or groundwater.
Date of Issue: ��j 19�_
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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