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BOX 29
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NINE
03792
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 w
WELL LOCATION
Street Addre Q T tlageC t Tax Grid Number'
zt-
WELL OWNER
Name
.ling Address
,.
,ten.., private
!� '�,. _O Public
USE OF WELL
1 - primary
2.- secondary
OL SIDENTIAL
0 BUSINESS
Q INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEA P 0 ABANDONED
0 FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL ❑ STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED -- /EST. OF DAILY USAGE Xo_�5 Sal
❑ REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION M ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
®DRIVEN
[-]DUG
®GRAVEL
0
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
Address. Y
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _2!�,_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET
at ) (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 drilling operations be contained on this
property and in such f manner as not to degrade or other se contaminate surface or groundwater.
Date of Issue: 19 C
ZA,.f`
Date of Expiration 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