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DEPARTMENT OF HEALTH
Division of Environmental. Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
V
PCHD PERMIT #
WELL LOCATION
Street Address
own Village City Tax Grid Number -
M _ -3 U
WELL OWNER
Fame
Mailing Address
2 S
I�Private
I V13 'Public
USE OF WELL
1 - primary
2 - secondary
tfRESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O.
AMOUNT OF USE
YIELD SOUGHT gpm /#
10 REPLACE EXISTING SUPPLY
O NEW SUPPLY NEW DWELLING )13
PEOPLE SERVED 5 /EST. OF DAILY USAGE` al
O TEST /OBSERVATION Q ADDITIONAL SUPPLY
DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
` u. t
WELL TYPE
DRILLED
DRIVEN
[]DUG DGRAVEL
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: Name�/(°� Address:
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
�ON SEPARATE SHEET JI/J`'-
(date) (sign ure)
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 -y (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 drilling operations be contained on this
property and in uch a manner as not to degrade or otherwis on inate surface or groundwater.
4
Date of Issue: /'r '�' e'- 19 -.5'
Date of Expiration 19 % Permit Issuing Official
Permit is Non - Transferrable
3/89
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
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Boyd Artesian Well Co., Inc.
R.D. No. 5 Rte. 52
Carmel, N.Y. 10512
(914) 225 -3196
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