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03322
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03322
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 .#
WELL LOCATION
Stre dress
1 Tax Grid Number
_&06 -.-
WELL OWNER
Name
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
Mailing Addr s
,`�3
UBLIC SUPPLY
O FARM
U INSTITUTIONAL
private
D Public
Q AIR /COND /HEAT Rt&P J O ABANDONED
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
USE OF WELL
1 - primary
2 - secondary
AMOUNT OF USE
YIELD SOUGHT S� gpm /# PEOPLE SERVED /EST. OF DAILY USAG 6 gal
Ll REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING EEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
Ini DRILLED
®DRIVEN
®DUG ®GRAVEL 0OTHER
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 N Address ;/J '1-
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES x NO v
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
r., «a..- ._..�...__� -.a .- �.. _ ...e -.. -.... ....s..w. ...• +O+�r ...a..- .r.�.��.Y- �r✓�...... +r..9w.... o -.... ..rC.•AO•. ...v+a�...
DISTANC$ °TO PROPERTY r'xt�N�'NEAtiES'r WA'T�k i�iN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON SEPARATE SHEET
(date) (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
Department attached to this permit.
3. Submit a Well Completion Report-on a form
requirements of the Putnam County Health
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 d . ng operations be contained on this
property and in such a manner as not to degrade or h ise con ate surface or groundwater.
Date of Issue: 3 19 3
Date of Expiration 2 2_ 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp: Orange copy: Well Driller