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03827
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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
treat Addre
wn Villa City
Tax Grid Number
P -"3 °
WELL OWNER
Name
Mailing Address
Ai gy_
)(Private
/ ❑ Public
E OF WELL
primary
2 - secondary
,RESIDENTIAL
0 BUSINESS
❑ INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED
O FARM O TEST /OBSERVATION ❑ OTHER (specify
O INSTITUTIONAL ❑ STAND -BY O
AMOUNT OF USE
I/ELD UGHT gpm /#
PEOPLE SERVED /EST.
OF DAILY USAGE gal
REASON FOR
DRILLING
❑ REPLACE EXISTING SUPPLY
❑ NEW SUPPLY NEW DWELLING
❑ TEST /OBSERVATION
EEPEN EXISTING WELL
Q ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
®DUG
OGRAVEL 0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
ALot No.
WATER WELL CONTRACTOR:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE-10- P::OP- ERri�- NROM-- A1EA--.REST - WAT'4L.R -MiIN '•
LOCATION PKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET C
ate) (si ature)
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 erations be contained on this ,
property and in such a anne as not to degrade or other 'se contamina surface or groundwater.
Date of Issue: Ali
Date of Expiration 19 Permi ssuing Official
Permit is Non - Transferra le White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
ON
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