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`v� 14 DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO UNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO 'CONSTRUCT A ATER WELL
PCHD PERMIT #' -
WELL LOCATION
Street Address
Town/Village/City Tax
Grid Number
WELL OWNER
flame
Mailing Address
)4Private
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
9BUSINESS
0 INDUSTRIAL
❑PUBLIC SUPPLY (3AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
❑ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED EST. OF DAILY USAGE gal
REASON FOR
DRILLING
ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
REPLACE EXISTING SUPPLY • O DEEPEN EXISTING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
n IR C• E.n V \
WELL TYPE
DRILLED
DRIVEN ODUG 13GRAVEL
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 Ar)6Rr0cy-' Address: Pk1mCArn
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES / NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
/ []013 REAR OF THIS APPLICATION ❑ 0 SEPARATE SHEET
(da ) (signature�.�.- - - --r'
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 s.hall:
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: 0%p-7- / 6 19
ri Permit Issuing OffrOal
Date of Expiration: 19_
Permit is Non - Transferrable White copy: H. D. File
Yellow copy: Building Inspector
2/87
Pink Copy: Owner,
Orange copy: Well Driller
/9'E, 58.00'
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