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03028
DEPARTMENT OF HEALTH
Division of Environmental Health.Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
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APPLICATION, TO -CONSTRUCT -"A WATER WELL'
PCHD
PERMIT # 110 7S• 9S
WELL LOCATION
Stre Ad rW
Town/Village/City � Tax Gri Number o
.WELL OWNER
Name Mai 1 g Add s ASPrivate
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY Q AIR /CON /HEA PUMP O ABANDONED
0 BUSINESS O FARM O TEST/ OBSERVATION O OTHER (specify
0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT S� gpm /# PEOPLE SERVED ---- -tEST. OF DAILY USAGE _45V al
REASON FOR
DRILLING
CE EXISTING SUPPLY 0 TEST/ OBSERVATION Q ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING f] DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
DUG
GRAVEL
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
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
Address:
YES NO
NAME-OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
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DI T*PsTO'VROPERTY FROM NEAREST WATER MAIN: -
SKWCH & SOURCES OF CONTAMINATION PROVIDED
-' U F- 0 O SEPARATE SHEET
EEI
ta(.di -W.' r
v
(signature)
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Lu 2� 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
thirt3, (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 haste products from such well drill g operations be contained on this
property and in such''' manner as no.t to degrade or oth wi a conta ate surface or groundwater.
Date of Issue: 19 g
Date of Expiration a 19 .(2 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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