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04787
DEPARTMENT.OF HEALTH
Division Of Environmental H%aUh . Services
TWO COUNTY CENTER — CARMEL, N.Y.. 10512 (914) 225 -3641
APPLICXTIdN ':To` CONSTRUCT A 'WATER WELL p,
WELL LOCATION
SIREEI AUORESS.
Hein A.
IAx GRiO NUMBER.
1100rA' /o7 �co •'oral.
i l�AuE P
WELL OWNER
NAME..
J6J�N ,l� JAU
AOORESS: ,/
• / /t / ®kE.ri�T'.rr. PD• Pe�c /�,t"�v,T,+ -,i 6�9�
9 PSIVATC
❑ .PUBLIC
USE OF WELL
)( RESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP . ❑ ABANDONED
0 primary-
O BUSINESS
O FARM O TEST/OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT
gpm. /N0. PEOPLE SERVED o2 / EST. OF DAILY USAGE gal.
REASON FOR
O NEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
ORILLING
JE REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE
DRILLED
F_� DRIVEN EJ DUG GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? _ YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 1.4
LOT NO-: 9-- // Bt %S'• Aer,
WATER WELL CONTRACTOR: Name Ala)eA Ap/AW JdA/ Address : j3gov rn A"rA_JW //*"ey'e/ t;
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: CYES — NO Svr,�' � •'
NAME OF PUBLIC -WATER SUPPLY: loalvota���Pi�d ies -r��sT TOWN/_g,(7�T
_
DISTANCE.. .TO PROPERTY. FROM NEAREST WATER..MAIN
�T
.LOCATION SKETCH.& SOURCES OF CONTAMINATION.
(date) t� (sig, ature) - --
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 W 11 Completion Report on a f rm p o ide by
the Putnam jCounty'Healt Departme t ;
Date of Issue:.l� 1
. Pe :it Issuing Official .
Permit is.Non- Transferrable
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