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BOX 19
02243
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02243
DEPARTMENT OF HEALTH
�. Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT .A WATER WELL 1 /
V P C H D PERMIT #1A) 1h__ q l
WELL LOCATION
t ress
To
llage Ci Tax Grid Number
WELL OWNER
Mailing Address
Private
O Public
USE OF WELL
1 - primary
2- secondary
VRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0PUBLIC SUPPLY
O FARM
M INSTITUTIONAL
❑AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
OABANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT S gpm /# PEOPLE SERVED-- /EST. OF DAILY USAGE -55 o Sal
REPLACE EXISTING SUPPLY O TEST /OBSERVATION LI.ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING). 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
ODUG
13GRAVEL
O
OTHER
IS WELL SITE SUBJECT
IF WELL IS LOCATED Ir
FLOODING?
YES 'Z'3 Z, NO
A REALTY SUBDIVISION, NAME OF S
IVISION:
Lot No.
WATER WELL CONTRACTOR: Name __J( Address:
IS PUBLIC WATER.SUPPLY AVAILABLE TO.SITE: YES. ENO
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
(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
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.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well dril ng operation be contained on this
property and in sup a �m+anner as not to degrade or oth r s ontami surface or groundwater.
Date-of Issue:
312 "l 19
Date of Expiration. 19 Permit Issuing Official
Permit is Non - Transfer able White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
its
PUTNAM COUNTY HEALTH DEPT. 014344
4 Geneva Road (914) 278-6130
Brewster, NY 10509 Date
i0e
Received of
T c-b
The $011 Dollars t I Of k
0
For -- --- ----
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