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03474
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914).225-3641
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PCHD PERMIT # dl!'sZ� f8
WELL, LOCATION
' Street Address
. c.hurt
To Village C't Tax Grid Number
� 3 / .. 21
WELL OWNER
Na a
Ma" ing Addres , op, rivate
b s- (.,Y Per I s k O Public
IM OF WELL
1 - primary
- secondary
,`Q't�ESIDENTIAL
('BUSINESS
( INDUSTRIAL
❑PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
. AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED Z /EST. OF DAILY USAGE 6 �� gal
REASON FOR
DRILLING
ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
,REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
.
WELL. TYPE
DRILLED
DRIVEN
ODUG
O GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WE IS'LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
('� c� `q3� �-c� Lot No.,
WATER WELL CONTRACTOR: Name 7,E� Address:
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
O ON REAR OF THIS APPLICATION SE
(date) (s
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.wel.l 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 b, the Putnam County
Health Department.
Date of Issue: % �� 19
Date of Expiration: 19 g/7 Permit Issuing a
Permit is Non - Transferrable White cbPY: H.D. File
Yell ' ldin o
ow Btu t
copy. 9 Inspec r
Pink Copy: Owner
287 Orange copy: Well Driller
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