Application to Construct a well
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APPLICATION TO CONSTRUCT A WATER WELL
DUTCHESS COUNTY · HEALTH DEPARTMENT i
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22 MARKET STREET. POUGHKEEPSIE. N. Y. 12601
(914) 431-2044 I
PLEASE PRINT OR TYPE I
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WELL LOCA nON t1iddlebush Road Wappingers Falls 615701353724
NAME ADDRESS 12569 10 PBIVAH
WELL OWNER Town of Wappinger Mi II St., Wappingers Falls, NY lZl EUBlIC
USE OF WELL o RESIDENTIAL o fUBUC SUPPLY o ,6IR/COND./HEAT PUMP o ABAN.QONED
1 - pnmary 1KJ 12USINESS o .fARM o lEST /OBSERVA TION o QTHER (specify)
2 - secondary o INDUSTRIAL o INSTITUTIONAL o STANO-BY 0
AMOUNT OF USE YIELD SOUGHT 5 gpm./NO. PEOPLE SERVED 32 / EST. OF DAIL Y USAGE 985 gal
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REASON FOR 00 liEW SUPPLY o PROVIDE ~OOiTlONAL SUPPLY o TEST/OBSERVATiON
DRILLING o REPLACE EXISTING SUPPL Y o Df.EPEN EXISTING WELL
I WELL TYPE I m DRILLED 0 DRIVEN 0 DUG 0 GRAVEL o OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF ~iELL IS LOCATED IN A REALTY SUBDIVISION, Nlu'l1E OF SUBDIVISION:
LOT NO.:
WATER WELL CONTRACTOR: Name J. 1. Eckerson, I nc. Addres s: Mil ton, NY 12547
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES X NO
Nlu'l1E OF PUBLIC WATER SUPPLY: TOWN/V/C
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN 1:1600 ft.
LOCATION SKETCH & SOURCES OF CONTAHINATION (Read instructions before completing)
C"::>-~ - Sa-re. p~~ - Il S~T f,S - A1TA~60
R!ECEiVED
SU?ERVISOR'S OfFICE
TOWN OF WAPPINGER
JAN 2 9 1985
28 January 1985
(da te)
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(signature)
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