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04178
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
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PCHD PERMIT a-V
WELL LOCATION
Street. Address
Ole
Town Village City Tax Grid Number
WELL OWNER
Name
Mailing Address • I/Private
C2 1 80 Ix �� F s ��� O Public
USE OF WELL
ice- primary
2 - .secondary
PRESIDENTIAL
D BUSINESS
11 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
M INSTITUTIONAL O STAND -BY O.
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__�al
J4 REPLACE EXISTING SUPPLY O TEST /OBSERVATION GI ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING) DEEPEN . EXISTING WELL Z-
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
An
Cy i P, lr 2,777 l? ' 09, _tai G E:7x i n 0
ti.
1
WELL TYPE
DRILLED
DRIVEN ODUG
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 -A -D i;-- Address: P t/
IS PUBLIC WATER SUPPLY 'AVAILABLE TO SITE: j rsiitEz/` BSI e- NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
°.
DISTANCE- -TO -WATER "MAIN- '` _ _. s..,.,...... ..._._.........- �._.,.__...__. _ _ _ - -. _._...._....
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED.
DON SEPARATE SHEET
ea
(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 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.
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Date of Issue: 4\� ��� 19� G
Date of Expiration: �19 % / ermit ssuing icia
Permit is Non - Transferrable ate copy: H.D. File
Yell Buildi.n
au copy. g �r
Rev. 10/88 Piz* Copy: Omer
Orange copy: Well Driller
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