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DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO. CONSTRUCT ~A WATER (WELLF
PCHD PERMIT #V�
WELL LOCATION
Street Address Town Village City Tax Grid Number
5// f- 2 !'G da� x ✓' 46 ipg - s- -
6 v -
WELL OWNER
Name
roIW,6 "_
Mailin Addre
Z 05" J ' / %.0 IC
;?.01- 86 7 -o?.SoS� C-tPrivate
T 0 0 y-O Public
USE OF WELL
1 - primary
2- secondary
[RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBL SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP O ABANDONED
.0 TEST /OBSERVATION 0 OTHER (specify
0 STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 1 /Jpm /# PEOPLE
SERVED Z /EST. OF DAILY USAGE3.S' gal
REASON FOR
DRILLING
ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST OBSERVATION
@f PLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
IdA Tek f-v
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WELL TYPE
QDRILLED
DRIVEN
E]DUG El GRAVEL D OTHER
IS WELL SITE SUBJECT'TO FLOODING? YES ENO
IF WELL.IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: NameXOjelf/ollhl a-: V' f Address: fi rh -gb/3 dyrf
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 PRnvTnFn
.3 ¢
[]ON REAR OF THIS APPLICATION
(date)
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. _
Date, of Issue: .2-619
Permit Issuing Official
Date of Expi rat io 719 D
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange cow: Well Driller
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