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00205
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
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WELL LOCATION
Street Address Town Village City Tax
Grid Numver
WELL OWNER
Name
7r F-Af OF /
Mailing Address
0 AIC C a g4AROAliv /C G05AAr Al.
ApPrivate
y. O Public
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0PUBLIC SUPPLY OAIR /COND /HEAT PUMP
O FARM 1 ® TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0ABANDONED
0 OTHER (specify
D
AMOUNT OF USE
YIELD SOUGHT 3""'f gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
0 NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
® TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
W E C
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WELL TYPE
DRILLED
DRIVEN ODUG
O GRAVEL
O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
DS
WATER WELL CONTRACTOR: Name 3D.YD Rfi S �r Address:
/ kmet,o
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 &N SEP TE SHEET
ay s M
date (signature)
gnature )
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 s.hall:
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 -6 19 %V
Date of Expiration: ( 19 Permit Issu ng cia
Permit is Non - ,Transferrable copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller;,
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