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04246
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04246
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION'TO'CONSTRUCT A WATER'WELL ,)
PCHD PERMIT #b ; A3
WELL LOCATION
Street Addr
G
s
- i
Town Vill, a City Tax Grid Number
WELL OWNER
Name
Mailing
A
Address Private
,.3 0 Public
USE OF WELL
4Pprimary
secondary
(RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify,
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE_ _gal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING
j] TEST /OBSERVATION 13. ADDITIONAL SUPPLY
DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
AS -
-
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL.
O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES y_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: LAIZE
Lot No.
WATER WELL CONTRACTOR: Name 040jf(Al Address: �un✓`' �'
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: i/ YES NO
NAME OF PUBLIC WATER SUPPLY: C�'l�Lr �I�u -�- TOWN /VIL /CITY h�S�rLL
DISTANCE TO PROPERTY FROM NEAREST"WATER MAIN: [_ /01j A :._4
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON SEPARATE SHEET
(date) (signatur
IV
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
thirt; (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
any and all water or waste products from such well
property and in such a manner as not to degrade or
Date of Issue: 19
to of Expiration 19 tj
1
'.t is Non - Transferrable White
ti
shall take appropriate action to assure that
dri ng operations be contained on this
er ise con inate surface or groundwater.
�&4w /&VIO
ermit Issuing Official
copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
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906 SOUTH ST.. PEEKSKILL. N. Y,
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