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BOX 23
02722
DEPARTMENT OF HEALTH
Division of"Environmental Health Services
4 Geneva Road;iBrewster, New York 10509
(914) 278 -6130
APPLICATION ' TO CONSTRUCT A WATER WELI;
PCHD PERMIT # d ��
WELL LOCATION
Street Address
l:- Ali"
To �iil
f i �,
ge City P Tax Gri
t L�
Nu r
WELL OWNER
Mailing ► dress
C> /v'�: - Lt
'
rivets
13 Public
USE OF WELL
1 - primary
2- secondary
O'RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT 4 7 gpm /# PEOPLE SERVED ---° /EST. OF DAILY USAGE -* a.g sal
AEPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13. ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WEL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
(1- ,'
4'1
! i
r/l •- - '
WELL TYPE -
CRDRILLED
ODRIVEN.
ODUG GRAVEL.
0 OTHER
IS WELL SITE SUBJECT.TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: — ~-
Lot No.
�
Iola
WATER WELL CONTRACTOR: Name dd� Address: Y V
IS PUBLIC WATER SUPPLY AVAILABLE_TO SITE:. YES' ►!" NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DIS`::Lvr "T�j PttePER ^v .FRO?rI:WF_AF�.cT WaT.R,R MATH;
LOCATION SKETCH & SOURCES OF CONTAMINATION, PROVIDED
OON 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)'Aays 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 contaminate surface or groundwater.
Date of Issue • _.' 19 �' ---�_. _.- �""�'„_• _
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable
3/89
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
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