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BOX 18
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IN
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61 IN,
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01960
TWO C NTY
DEPARTMENT OF HEALTH
Division of Environmental Health.Services
CENTER - CARMEL, N.Y. 10512. (914)225 -3641
"— APPLICA- tfdlV':TO CONSTRUCT - A .WATER WELL `
PCHn PRRMT.T fFl11'AQ�-S !Jl
WELL LOCATION
treet ddress To Villa a City Tax Grid Number
Q r �re� a P7
WELL. OWNER
Name ,,
Meiling Address
',
pPrivate
Lgc7n: �F4 3 ❑.Public - .
USE OF WELL
1 - primary
2- secondary
(.RESIDENTIAL
0 BUSINESS
11 INDUSTRIAL
❑PUBLIC SUPPLY ❑AIR /COND /HEAT PUMP 0ABANDONED
O FARM .❑ TEST /OBSERVATION ❑ OTHER (specify'
U INSTITUTIONAL O STAND -BY O.
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE SERVED /EST. OF DAILY USAGE a.gal
REASON-FOR
DRILLING
EW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION,,
GlffPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
-
e
WELL TYPE
DRILLED
E]
DRIVEN
EIDUG
[DcRAVEL
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
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO ;.as -304 6
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO'PROPERTY FROM NEAREST WATER" MAIN:'-
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
V . l ON REAR OF THIS APPLICATION (.ON SEPARATE SHZET.
dat eX (signat re)
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 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 provided by the Putnam County
Health Department. n
Date of Issue: 19 -
-° Permit Issuing ficia
Date of Expiration: 19 S�
Permit is Non - Transferrable Wh- ,copy: H.D.-File..
Yellow copy: Building-Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller