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BOX 32
04293
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
278 -6130 ,
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address
7 r"+ P
Town Village City
f v VO-1I
Tax Grid Number
g3 . ' -- / -3S
WELL OWNER
Name
Mailing Address
C t8O;x /2 P1jh/Am I/6./
/ Private
/V `/ OPublic
USE OF WELL
1 - primary
2 - secondary
Q(RESIDENTIAL
0 BUSINESS
D INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED
O FARM O TEST /OBSERVATION 0 OTHER (specify
O INSTITUTIONAL ❑ STAND -BY U
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE SERVED 5 /EST. OF DAILY USAGE al
REASON FOR
DRILLING
13 REPLACE EXISTING SUPPLY ❑ EST /OBSERVATION 13 ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN DDUG
OGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Laze
Lot No.
WATER WELL CONTRACTOR: Name 1 Rrt'ieSic fl We Al CO Address ,52 aa Mel
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO SUmM�' "rz-4er
NAME OF PUBLIC WATER SUPPLY: Lok-e- ReeK_5k TOWN /VIL /CITY
DISTANCE TO PROPERTY FROMTNEAREST -WATEi _MkTN:"
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET
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.
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: ., " -12
Zee._3 19_L'_�_
Date of Expiration,42��Z?_ -Z___. 19 e!:9
Permit is Non - Transferrable White
3/89 Yelloi
shall take appropriate action to assure that
drilling operations be contained on this
otherwise con tami.nat ur-fac-eer_ roundwater.
.ermit ssuing Official
copy: HD File Pink copy: Owner
a copy: Bldg. Insp. Orange copy: Well Driller