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BOX 24
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02839
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
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WELL LOCATION
Street Addre
.2-, v �.1..�
To
C Tax Grid Number
WELL OWNER
Name
Mailing Addr
�,
Private
Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PTDIP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
Q
AMOUNT OF USE
YIELD SOUGHT .5' gpm /# PEOPLE SERVED ---- /EST. OF DAILY USAGES 00 gal
REASON FOR
DRILLING
13 REPLACE EXISTING SUPPLY p TEST /OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING EEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
fi
WELL TYPE
93DRILLED
ODRIVEN
ODUG
OGRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES )< NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name _l ,1� � e- Address: /li
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _Y—' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE_ TO PR3P� T•� rRi3'r1. t+i A3iE 7''.GiaTr,?.. SAT.N.. - - - -_ - _ - -
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 drill perations be contained on this
property and in such manner as not to degrade or oth contaminate surface or groundwater.
Date of Issue: 2s 19 ��
Date of Expiration a D 19 i Permit Issuing Official
Permit is Non - Transf r le % White copy: HD File Pink copy: Owner
3/89�l C Yellow copy: Bldg. Insp. Orange copy: Well Driller