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00624
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Address
QUA . f/G9LC 2Y7
Town Village City Tax
%}1 %E�E'SU/�
Grid Number
0 / /
WELL OWNER
Name
Eli P- LAill
Address
1a D E- %ah •
r i vA to
O Public
USE OF WELL
1 - primary
2 - secondary
ErRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
❑ BUSINESS O FARM ❑ TEST /OBSERVATION
❑ INDUSTRIAL 13INSTITUTIONAL CI STAND -BY
O ABANDONED
❑ OTHER (specify
D
AMOUNT OF USE
YIELD SOUGHT
gpm /#
PEOPLE SERVED_ /EST. OF DAILY USAGE i�-t,40gal
REASON FOR
DRILLING
EW SUPPLY
REPLACE EXISTING
SUPPLY
❑PROVIDE .ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
❑TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
ffDRILLED
DRIVEN
DUG
GRAVEL
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 R��pp11 5 - Roll e 52 „ ° � � �0 Address :
IS PUBLIC WATER SUPPLY AVAILABL TOe I 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 REAR OF THIS APPLICATION 0 SE A
(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 a Putnam Countyi.
..Health Wartment.
Date of Issue: 19-4F
Date of Expiration: 11 19 d d rmit s ng f icial
Permit is Non- Transferrab e
8/86
B
SON
/,Gle-lr
Boyd Artesian Well, Co.., Inc.
R. D. No. 5 Rte. 52
Carmel, N . Y. 10512
(914) 225 -3196
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