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03414
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
PCHD PERMIT #
WELL LOCATION
Street. Address Town/Village/City Tax Grid Number
WELL OWNER
Name Mailing Address
p-'
IMP=ivate
O Public
U E-6 L
- primary
econdary
Q RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL U INSTITUTIONAL- O STAND -BY.
0 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHTgpm /�6 PROPLE SERVED /EST. OF DAILY USAGE �f�', 8a1
Ll REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION E2. ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
MDRILLED
DDRIVEN
❑DUG
GRAVEL.
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Y— NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. n
WATER WELL CONTRACTOR: Name Q /j0w ;0A Address: ?Ag6Ea 5 r
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1,,/ NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
ROAR.TY "FROM NEAREST. WATER-- t1AIh::
LOCATION SKETCH & SOURCES 'OF CONTAMINATION PROVIDED %
�� ,
/� h q 1`1 . Z"4
N SEPARATE SHEET
(date)' ignature)
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 waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or othe contamin a surface or groundwater.
Date of Is 1 19 qtl
Date of Expiration 0' 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: B1dg..Insp. Orange copy: Well Driller