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1\0 DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OL OUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
PPLICATION TO CONSTRUCT A WATER WELL
PC_Hn PRRMTT &1 J1 17'11)
WELL LOCATION
Street Address
145 Cross Rd.
Town/Village/City
Patterson NY
Tax Grid Number
WELL OWNER
Name
Fred Schmidt
Mailing Address
145. Cross Rd. Patterson NY
QPrivate
0Public
USE OF WELL
1 - primary
2- secondary
13 RESIDENTIAL
O BUSINESS
Q INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM p TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT gpm /4E PEOPLE SERVED /EST.
8 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION
❑ NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL
OF DAILY USAGE_ gal
Ll: ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
Ex i, S 11. U ' l S
ins r
G ,S
WELL TYPE
®DRILLED
ODRIVEN
DDUG
OGRAVE.L
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name P•F.Beal.&Sons,Inc. Address: POBoxB.,Breuster,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:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON 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
thirt3c (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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 other contaminate'surface or groundwater.
Date of Issue: l- 19 qd r-1g'1W'
Date of Expiration jb 19'q 2.- Perm Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller