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BOX 34
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04576
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO UNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
- APPI CATION TO CONSTRUCT `A WATER WELL
PCHD PERMIT #� Df
WELL LOCATION
Street Address
0- bCV -1-9
To V llage City Tax
D 3 u y� uct ec .
G id Number
WELL OWNER
Name
7ps �'
M it ' n iAddress
g /
rivate
O Public
USE WELL
1 primar
2- secondary
O RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
d INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
,.
AMOUNT OF USE
YIELD SOUGHT e gpm /# PEOPLE SERVED .� /EST. OF DAILY USAGE - gal
REASON FOR
DRILLING
0 NEW SUPPLY PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
' n
WELL TYPE
DRILLED
DRIVEN
ODUG
GRAVEL
❑ OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: AZD
Lot No.
03l r� ��
WATER WELL CONTRACTOR: Name&/��n� Ancdr imian inc- Address: 4AP t n t�arl a..�
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: "—'— TOWN /VIL /CITY
-DISTANCE TO "PROPERTY- FROM NEAREST 'WATER MAIN: ----� - "
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
�,p [O ON REAR OF THIS APPLICATION MON SEPARATE SHE T'
t7��'1S 7 ` ^•
(date) `�' ( gnature)
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. tDisinfect 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.
Date of Issue: �`� �3 19
- -T 11— hermit Issuing Officia --
Date of Expiration : / 197_
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
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