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02507
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL n� C
PCHD PERMIT # �(Jd
WELL LOCATION
tre Ut=dss
To
=ilage/City Tax
Grid Number' /, -'
4
WELL OWNER
Name
Mai ' n Ad �
rivate
O Public
ITSE OF WELL
(9--primary
2- secondary
„ IDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY
0 FARM
O INSTITUTIONAL
0 AIR /COND/HEAT PUMP
❑ TEST /OBSERVATION
O STAND -BY
❑ ABANDONED
❑ OTHER (specify
O
` AMOUNT OF USE
YIELD SOUGHT_ gpm /# PEOPLE SERVED =-- /EST. OF DAILY USAGE _�CV gal
REASON FOR
DRILLING
ONEW SUPPLY PPROVIDE ADDITIONAL SUPPLY
❑ REPLACE EXISTING SUPPLY PEN EXIS ,IjiG WELL
0 TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
[DDRIVEN
aDUG
®GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES t-"' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
t YES
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: '
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED !rte
ON REAR OF THIS APPLICATION []ON SEPARATE SHEET
date) (s gnature) r"
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.
Date of Issue: �'vt� Z� 19 ermit I Official
1
Date of Expiration e`
ssuing
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
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p. .._y..._ iIJTTNAi i i:OVIr1TV DEI'ART�VIENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project (T)(V)
Year of Construction Size of Parcel (:57
C7
SECTION B. TOPOGRAPHY (Please check all appropriate boxes) .
1. ❑Hilly ❑Rolling ❑Steep S1ope"C1entle Slope ❑Flat
2. ❑Evidence of wetland OLow area subject to flooding ❑Bodies of water
❑Drainage ditches Clock outcrop
3. Property lines evident?
. Watercourses - exist_on, or.:adjacent to parcel:
5. Existing individual wells within 200ft of the existing SSTS? ❑
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ❑Level ❑ ntle Slope ❑Steep slope
B. ❑Nell drained ❑Moderately well drained
❑Somewhat poorley drained .❑Poorly drained
C. (Primary & Reserve) o
xtremely limited omewhat limited ❑Adequate ft x ft
° D. INSPECTION Date Inspector.
ONo evidence of failure DEviden.ce of/failure` . Evidence of seasonal failure
H
.
----------------------------------------- -- (Indicate North)
Y
r�� HOtiS=
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
Metal ClConcrete nPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3.. Gallies
4
O2 Indicate setbacks, front stxeet, backyard, and side , and dun�nsiaps:.._:
_ Y . _ ...._...
- - (3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streamshti elands)
SECTION E. EXISTING WATER S
[3PWS
MShared well
COiMYENTS : GY le�
'ELdividual well
DDrilled ODug
®Casing above ground
7