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03942
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL ,/
PCHD PERMIT #I A
IS WELL SITE SUBJECT TO FLOODING? YESNO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:._
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
_ZYES N
t.
S /LL TOWN /VIL /CITY
LOCATION SKETCH .& SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION N S PARATE SHEET
(date) (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
ter_
r
0
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.
Date of Issue: 3"-'/ 19 `
Date of Expiration:�Zui-r 19 9 d
ficia
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
Street Address
, Town V' la a /City Tax Grid Number
WELL LOCATION
ILG
•
i�2 -�&A -
WELL OWNER
Name
Mailing Address mate
0 Public
USE OF WELL
ENTIAL
❑PUBLIC SUPPLY 0 AIR/ COND /HEAT PUM�29 PANDONED
P Y 1 - rimar
3 BUSES INESS.
0 FARM 0 TEST /OBSERVATION HER (specify
2- secondary
0 INDUSTRIAL
U INSTITUTIONAL 0 STAND -BY O
AMOUNT OF USE
.YIELD SOUGHT__�gpm /# PEOPLE SERVED
X77 / EST. OF DAILY USAGE al
REASON FOR
ONEW SUPPLY
NpOLUOVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
❑REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DETAILED
OLlS�
S
REASON FOR
DRILLING
WELL TYPE
LED
DRIVEN
DUG GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YESNO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:._
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
_ZYES N
t.
S /LL TOWN /VIL /CITY
LOCATION SKETCH .& SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION N S PARATE SHEET
(date) (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
ter_
r
0
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.
Date of Issue: 3"-'/ 19 `
Date of Expiration:�Zui-r 19 9 d
ficia
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
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