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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT
# 0.-. yo.- g 1,-
WELL LOCATION
S=9kI&L Address
Town Village City Tax Grid Number
0 iP - A-3o-
WELL OWNER
Name
lA/
Mailing Address
► f
WPrivate
S i_z a /�a t. Public
USE OF WELL
1 - primary
2 - secondary
OrRESIDENTIAL
„ 0 BUSINESS
® INDUSTRIAL
® PUBLIC SUPPLY
0 FARM
U INSTITUTIONAL
���
Q AIR /COND /HEAT PUMP F7 ABANDONED
O TEST /OBSERVATION O OTHER (specify,
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED _-f' /EST. OF -DAILY USAGE al
ArREPLACE EXISTING SUPPLY O TEST /OBSERVATION' D. ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
ODUG
aGRAVEL
•
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ){ NO
IF WELL -IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
p q E . M -4eN sr.
WATER WELL CONTRACTOR: Name 6& / �}a,�,p s'y� ) , s-� � . Address : �� � as A1.4
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >( NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
bI§TANCE TO 'PROPER'11 FROM NEAREST WATER MAIN:` "
LOCATION SKETCWON SOURCES OF CONTAMINATION PROVIDED
SEPARATE SHEET
'j 1919.2
(d to ) Vignature)
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: IYA1 /J 19�
Date of Expiration f'1 / 19
Permit is Non - Transferrable Whi e
3/89 Yel o'
shall take appropriate action to assure that
drilling operations be contained on this
Iherwise contaminate surface or groundwater.
7cppy: Issuing Official y: HD File Pink copy: Owner
Bldg. Insp. Orange copy: Well Driller
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