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02746
�D DEPARTMENT OF HEALTH
Division.of Environmental Health Services
T 0 OUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER yWELL
+ �a
PCHD PERMIT
WELL LOCATION
Street Address
42 d(
Town/Village/City Tax
v , ahti /e.
Grid Number
WELL OWNER
I Name
Xi l
Mailing Address
aTrivate
O Public
USE OF WELL
1 - primary
2- secondary
fel6iiIDEi(TIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE .gal
REASON FOR
DRILLING
CINEW SUPPLY O P VIDE ADDITIONAL SUP LY
OREPLACE EXISTING SUPPLY 01EEPEN EXISTING WELL
O T OBSERVA ION
DETAILED
REASON FOR
DRILLING
e-_ ,-
WELL TYPE
BILLED
DDRIVEN
DDUG
[]GRAVEL
Q
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES •-----NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
s"
WATER WELL CONTRACTOR: Name ,�n �� y '��y` Address: IQ > !:� 42.> <a v (/d Ile
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ---~"-IT0
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
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 requi ements of the Putnam
County Health Dep rtment attached to this per t.
3. Submit a Well Co letion Report on a form pr de
Health Departure � U
Date of Issue: 19
Date of Expiration: g� �--- ermi t Isfii ng Offi ci f
White
Permit is Non - Transferrable coPY: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller