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03023
UtrAK I MUN I Ur r1tAL I h
Division Of Environmental H%axh Services
TWO COUNTY CENTER - CARMEL,. N.Y..10512 (914) 225 -3641
_ .... ... ..AP PLIC: >TInN- :;Tr_'.•. CONSTRUCT j7% IIATER W 1 E - ,..
WELL LOCATION
SJREc l
Cc ?�u5�`ncv�
WWNiV1LLAGE1G11T IAX GAW NmibER.
-n Ua(� y: . �j
WELL OWNER
NAME. •
Vi di
ADDRESS:
- f�a -r�v� c,a X11 �-d� �r�r s.., � J•Ny
P61VATt
O EUBLIC
USE OF WELL
(dRESIDENTIAL -t ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
O BUSINESS
❑ FARM ❑ TEST /OBSERVATION ❑OTHER (specify)
2 - secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY ❑
AMOUNT OF-USE
YIELD SOUGHT
9pm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE —+— 921.
REASON FOR
QINEW SUPPLY
M ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
Cd gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
.WELL TYPE
DRILLED
F_� DRIVEN F_� DUG . GRAVEL Ej OTHER
IS WELL SITE.SUBJECT TO FLOODING? _ YES �% NO
IF WELL IS LOCATED;IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
UW LOT NO_:
WATER WELL CONTRACTOR: Name �{ 1 F. '3V_C0 Address : q ?16L ews *r u�
IS.PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO.
NAME OF PUBLIC -WATER' SUPPLY: - TOWRI/V /C
DISTANCE TO PROPERTY FROM-..NEAREST WATER- .'MAIN 1
- LOCATION SKETCH .& SOURCES,OF CONTAMINATION•
Iv --lbw �� . , L�•y '
(date) (signature) Sd' A�(
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 for provided by
the Putnam County Health..Departme t
Date of Issue: ( ` 19_r 1
.i
• P urmit Issuin Of icial .
• Permit ...is .Non - Transferrable � . • . . : •
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