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61.08-1-32 & 61.08-1-33
BOX 23
02742
TW COUNTY
DEPARTMENT OF,HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION, T,O,,:CON$T :RUC-- T-;;A,- :WATZR. -WELL.
PCHD PERMIT # D
WELL LOCATION
. � Street Address Town Village Cit Tax
�c �Ct.M_
Grid Number
WELL OWNER
Nam e A Mailing Address
a r-Ft V, it V
OPr vate
_tae.,:l Pul VI(kitew .O Public
USE ' OF WELL
1 - primary
2- secondary
CI RESIDENTIAL 0 PUBLIC SUPPLY
0 BUSINESS O FARM
0 INDUSTRIAL O INSTITUTIONAL
❑AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
OABANDONED.
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT <_gpm /# PFOPLE
SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
0 NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
IZREPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
lr. 1.'V (,U 0 0 Z
f ---
WELL TYPE
DRILLED
DRIVEN
E]DUG
GRAVEL
®
OTHER
IS WELL .SITE SUBJECT TO FLOODING? _ ` YES _No
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
IWATER WELL CONTRACTOR:, Name ,l A
IL
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO 3l 4
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DIS,TANCE:.T.O PROPERTY.JFROM NEAREST WATER MAIN:. _ }
LOCATION SKETCH & SOURCES OF CONTAMINATION
ON REAR OF THIS APPLICATION
/�- a3-�
(date)
PROVIDED
PERMIT
SEPARATE SHEET
(signatu e)
TO CONSTRUCT A WATER WELL
This permit to construct one water well as s,et� forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided.that.wi.thin 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: 2 19
Date of Expiration:(16 Xi 19 '1--6 Permit ssuing Off,icial
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
Boyd Artesian WeN,
R. ®. N®. 5 Rt
rme
(914) 225-31c,
Pop ho
WgIl
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E)w
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