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HomeMy WebLinkAbout0910DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.39 -1 -28 BOX 10 1 �A . ti r� rI Is 1 -0 t R F I'L 1 r I I 00910 n PUTNAM COUNTY DEPARTMENT OF HEALTH � . DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL S please print or type PCHD Permit #-W11-1T - - -- Well Location: Street Address: TownNillage Tax Grid t Map Block t(s) Well Owner: Name: Ad ess: Use of Well: Residential Public Supply Air / Co at Pump I ffigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) X Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ......................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes Name of Public Water Supply: / Town/Village/4 /L' Distance to property from nearest water main: No ' Proposed well location & sources of contamination to be provided on separate sheet/plan. Dat(, :_ Applicant Signature: /-4, - - _ L-- -- -- PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue D�,) Permit Issuing Official: Date of Expiration / Title: p� h /, ` ,Pa l.FA Sirwul yY rto Permit is Non -Trans errable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 J