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BOX 26
03151
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03151
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
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�PCHD PERMIT #W 9(,V-
WELL LOCATION
-- Street Ad/dress
-J- 1,1"JV I-Ak
Town/Village/City �c-
/�/✓hn L
Tax Grid Number
Q 7A -GC7C5 °OVU I -U 06 -0 00
WELL OWNER
Name
O fiNN ��) I
Mailing Address
4 T/lo �i3�v Po
CoPrivate
N 10S-06 O Public
USE OF WELL
1 - primary
2- secondary
+RESIDENTIAL
D BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify,
O INSTITUTIONAL O STAND -BY D
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED _5r
/EST. OF DAILY USAGE- D O gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION GIADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING ' DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
DUG
GRAVEL
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 aj j4a_1j .S1A,,d QJE l qO� _ Address: Or- d G%Yr.j l a� / Z-
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES x NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM. NEAREST_ WATER MAIN.: -
LOCATION SKETCH & SOURCES OF CONTAMINATION
ON SEPARATE SHEET
1 (date
PROVIDED
(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 drillin operations be contained on this
property and in such manner -As not to degrade or other t. surface or groundwater.
Date of Issue: 10 19 �J
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transfers le White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller