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DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
+�- APPLICATION 'TO'� -CONSTRUCT "" At 'WATER' WELL" " "'"
PCHD PERMIT
WELL LOCATION
Street. Address
/r 0 Q/t 6OWC
Town Village City Tax
(ZC sue✓ Al V.
Grid Number
WELL OWNER
Name
S C EC 1 t.6
Mailing Address ,Wrivate
D ir/ L - Olt Cli Si tk. 4191. /a-S09 O Public
USE OF WELL
1 primary
2- secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM p TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
_
O ABANDONED
p OTHER (specif ;y,
O
AMOUNT OF USE
YIELD SOUGHT _ gpm /# PEOPLE SERVED IL /EST. OF DAILY USAGE J a ga.
REASON FOR
DRILLING
VREW SUPPLY [)PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
QifD GJA?P'c-
PhFSSt1j? r .
_
WELL TYPE
DRILLED
❑DRIVEN
❑DUG
❑GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _j<_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: _
Lot No.
WATER WELL CONTRACTOR: Name Address: Q �u� e'� t�e"
4l' /BSQy _
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _X No
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION ❑ WS S ET
�- 6 -8Z
(date) (sign ure)
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 s.hall:
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.
Date of Is sue: ,���,'/ 19 _
Date of Expiration 19 Permit Issuing Offl cia. --
White Permit is Non - Transferrable copy: H.D. File
'in
Ye11oW copy. Buz ld
g Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
t U S Eb A16'
11-W 101'x�
�: .Y(�J+: IfIViI/ Ztj % ;g'G ✓rq �f .