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04299
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 _
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APPLICATION TO CONSTRUCT A WATER WELL
PCHD •PERMIT # /�
WELL LOCATION
tre5t Address
Town Vi,
age City Tax Grid Number
WELL OWNER
Name
�-_
Mailing
C3.
Address
Private
2. DPublic
USE OF WELL
- primary
2- secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
0 INSTITUTIONAL
O AIR /COND /HEAT PUMP O ABANDONED
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /#
REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING)
PFOPLE SERVED- /EST. OF DAILY USAGE_kal
O TEST /OBSERVATION 13 ADDITIONAL SUPPLY
® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
OM VXX_'
v f ' .i'1 r
/ V C4
WELL TYPE
DRILLED
ODRIVEN
ODUG
OGRAVEL OOTHER
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 Q0`r%-N'j0L•n (3_( CSOn T(1C, Address : ]S()- ry ,
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO -PROVERTY- FROM-NEAREST`WATER MAID : '
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
s P C11 A 17
(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 shall take appropriate action to assure that
any and all water or waste products from such. we "il drilling operations be contained on this
property and in such a 'manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue:.
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
riper
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