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3.19 -1 -20
BOX 2
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO UNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
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PCHD PERMIT F J ?'
WELL LOCATION
Street Address
Route 311
Town/Village/City Tax
Patterson NY
Grid Number
WELL OWNER
Name
Larry Hannan
Mailing Address
PO Box 203, Patterson NY 12563
qPrivate
13 Public
E OF WELL
- primary
2 - secondary
tj RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
t] INSTITUTIONAL 0 STAND -BY
0 ABANDONED
0 OTHER (specify
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AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED 3-5_/EST. OF DAILY USAGE � 6"'-Jgal
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY
REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
0 TEST /OBSERVATION
DETAILED
REASON FOR
.DRILLING
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WELL TYPE
®DRILLED .
DRIVEN.
DUG
GRAVEL
OTHER
'IS WELL SITE SUBJECT TO FLOODING? YES g NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name P.P. Real k . Sons,,Tnc. Address: PO Box B.,Brewster,NY
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �..
LOCATI� SKETC SOURCES OF CONTAMINATION PROVIDED
C, _ / CON REAR OF THIS APPLICATION .
( - �signdture
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.
bate of Issue: ' �� 19
Date of Expiration: 19 Perm-it Issuing f cla
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2 87 (ramp- mnv! Wal 1 nri 11 ar
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Request
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No. '. 'Street " . = ToWn
ZNi No.
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— Can plianee. `.
:- Complaint Ccrnp _
MAILING-- ADDRESS,
_ ' • Firial: "
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P:O. Boac.:_ .: Post Office-
Zip Code
Group Illness .
Construction
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" TELEPHONE _
—
Rei.nspectign
1 y
PERSON IN. CHARGE .:
- Field, _Sampling Only
OR. INTERVIEWED
Field Conference
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Name and 'Title
f ';TYPE,
o
'DATE, FACILITY
TIME. �. .. 3 _TIME LEFT ' . l
Explain
FINDINGS':
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kt
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TELEPHONE•
-INSPECIQR: i
Signature and Title
PERSON IN _CHARGE OR 'INTERVIEWED:
'I
acknowledge this Field Activity Report.
SIGNATURES
` 9.
- 6/86 .,
TITLE: