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BOX 4
00110
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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
PCHD PERMIT # W 3o-9
WELL LOCATION
Street Address Town W yage/City Tax Grid Number
WELL OWNER
V IName
' l�f
Ma' ling Address
V "P_ kX• l
a(Private
OPublic
USE OF WELL
1 - primary
2- secondary
id RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT _gpm /# PEOPLE SERVED /EST. OF DAILY USAGE,�Db Sal
0 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 12. ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
1
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
!a-(A.) — LzrCTT14
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WELL TYPE
®.DRILLED
ODRIVEN
ODUG
OGRAVEL
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 V 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
(date)
Vkl_ 1'_�5
(sign ure) IV
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
thirt3• (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 such a manner as not to degrade or otherwise con ' groundwater.
Date of Issue: 19 �
e:�` ,
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