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04620
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04620
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 #
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Namewil�__ -- Address
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES H % ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE. *.TO PROPERTY FROM NEAREST WATER: MAIN:_=
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON 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
thirt }, (30) days of the completion of water well construction, the applicant shall:
z..
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 well drill perations Pe contained on this
property and in such a manner as not to degrade or oth w' contamin urface or groundwater.
Date of Issue: 2 2_ 19� ,c5/�
Date of Expiration 2 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
Street Address Town/Village/City
Tax Grid Number
WELL LOCATION
/ /mvv 4 ME
Name Mailing Address
OPrivate
WELL OWNER
ivBi'-i��✓ l �vei�n
Public
L
RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND
EAT PUMP O ABANDONED
1 - primer
0 BUSINESS 0 FARM 0 TEST /OBSERVATION O OTHER (specify,
- secondary
13 INDUSTRIAL O INSTITUTIONAL 0 STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED
/EST. OF DAILY USAGE___gal
REPLACE EXISTING SUPPLY O TEST/ OBSERVATION
12. ADDITIONAL SUPPLY
REASON FOR
DRILLING
0 NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
DETAILED
s'�w
REASON FOR
DRILLING
WELL TYPE
DRILLED DRIVEN DDUG
OGRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Namewil�__ -- Address
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES H % ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE. *.TO PROPERTY FROM NEAREST WATER: MAIN:_=
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON 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
thirt }, (30) days of the completion of water well construction, the applicant shall:
z..
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 well drill perations Pe contained on this
property and in such a manner as not to degrade or oth w' contamin urface or groundwater.
Date of Issue: 2 2_ 19� ,c5/�
Date of Expiration 2 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
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