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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APFLICATIONwTU-- CONSTRI3CTi -A:: WATER WELL--;'
/e rt ? 7PCHD PERMIT #U
WELL LOCATION
Stre dress
V
la t Tax Grid Number
WELL OWNER
N e ��
(f
ai� Address
Public
USE OF WELL
1 - primary
2- secondary
A-RESIDENTIA
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
(3 AIR /COND /HEAT PUMP O ABANDONED
O TEST /OBSERVATION "O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 6" gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__gal
O REPLACE EXISTING SUPPLY O T 6$SEA Q ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW DWELLING EEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
'
WELL TYPE
®DRILLED
®
DRIVEN
ODUG
O
GRAVEL. O
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 T eTE 7" YES x NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
- ;,:DISTANCE TO PROPERTY. FROM,NEAREST -WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET �n
(date) ) ' (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
thirt3! (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 o erations be contained on this
property and in such a ma ner as not to degrade or otherw se ontaminate surface or groundwater.
Date of Issue: ,v 1 19�
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
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