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00109
DEPARTMENT OF HEALTH
Division of Environmental Health Services
Y CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
Dour% All/.1_19
WELL LOCATION
Street Address
mooviem_J� tA P-4
Town/Village/City Tax
_P La!--
Ism
Grid Number
0 a pS
WELL OWNER
Name Mailing
0 � VSS� , S'7 �
Address -eX 1i §LPrivate
moo vta I . * CO*ZA- &,_ 0 Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY QAIR /COND /HEAT PUMP
9 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY
0ABANDONED
❑ OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT_ gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
0 NEW SUPPLY
OREPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
:,- .KDEEPEN>'EXISTING,' =WELLO
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
'
WELL TYPE
DRILLED DRIVEN
ODUG
13
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES K NO
IF WELL IS LOCATED IN A.REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL .CONTRACTOR: Name A- I.,V&'COL&eAddress`(�+ C4�4W4aA "1 aSla-
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 REAR OF THIS APPLICATION WON 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.
Date of Issue: 7 S 19
Date of Expiration: 19 Permit Issuing fici
Permit is Non - Transferrable Whits copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller