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04695
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
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PCHD PERMIT # uv (AI
WELL LOCATION
,,et Addr
s T 1
e C Tax
Grid Number
WELL OWNER
N e
Z ling Address
Wtrivate
D Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0PUBLIC SUPPLY QAIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
O INSTITUTIONAL 0 STAND -BY
0ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
.Sr gpm /# PEOPLE SERVED - LEST. OF DAILY USAGE OO Sal
REASON FOR
DRILLING
PLACE EXISTING SUPPLY 0 TEST/ OBSERVATION M ADDITIONAL SUPPLY
0 NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL
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:
IS y
re
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES
NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
,.DISTANCE-TO. PROPERTY . EROM..NEAREST. WATER. MAIN:
LOCATION SKETCVON SOURCES OF CONTAMINATION PROVIDED
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 shall take appropriate action to assure that
any and all water or waste products from such well drills perations be contained on this
property and in such.a ma Ter as not to degrade or other hs Lcontam in surface or groundwater.
Date of Issue: 3 19
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
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MAP d� SURdEY
LOT. 04: 47, 48 , 149
50, 51 , 52. 53. «r
LAKE PEEKSKILL - SECTioAJ' }:,V„
(FILED MAP Ns. l85-C
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LICGNSE NQ. 415¢
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LAttE CARMEL, IUEW YORK
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