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03047
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT 4
WELL LOCATION
Town Village�ity Tax Grid Number
Street Addre�s� //��''
WEL OWNER
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Name
30'" 0 S e�a
Mailing Address
•-:kc- o"
�P v--e / o/
ivate
OPublic
USOF WELL
primary
2- secondary
J24k9SIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
U INSTITUTIONAL
❑ AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify,
0
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED � EST. OF DAILY USAGE�al
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13 ADDITIONAL SUPPLY
SUPPLY NEW DWELLING M DEEPEN EXISTING WE L
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
'' .- o_ ter,
o
G o ,4 .o ,' v
•—
WELL TYPE
tfDRILLED
DRIVEN
®DUG
GRAVEL
OTHER
IS WELL SITE SUBJECT JO FLOODING? YES .?�`~NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES
NAME OF PUBLIC WATER SUPPLY:./ TOWN /VIL /CITY
"- ""DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ,.
/ARATE SHEET �
(date) TsIgn ature) .
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
thirt��'(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 drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: �/ S C711 / /
Date of Expirations 19� Permit Issuing Offici
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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