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BOX 15
01656
PUTNAM COUNTY DEPARTMENT OF HEALTH
'DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
pease pnint or type PCHD'Perfnit #- ...
Well Location:
Street Address: Town/Village Tax Grid # Z
40:� -Qr— / Map Block Lot(s)
Well Owner:
Name:
Ad ess:
,
!del
Use of Well:
� Resident Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought S� gpm # People Served — . Est. of Daily Usage -ro ogal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwellin _�< Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
?s well site subject to flooding? ................................................. ............................... Yes No 7-L'
Is well located in a realty subdivision? ............ Yes No x
,Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available to site? .................................. ............................... Yes No
Name of Public Water Supply: ' Town/Village
Distance to property, from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
iQ,
�D 42�
Date: D Applicant Signature:. .
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." ., revision or alteration
of the approved plan requires anew permit. Well to be constructed by a water we ll 'ller ce ' ied by Putnam
County:
,�.
Date of Issue C Permit Iss fficial: ,G
Date of Expiration Title:
Permit is Non-Transfeirible " 1
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
c.
Street T
Town, _ .. S
State z
zip
PERSON IN CHARGE c
c�i�Ii 3
.RT)
Name and;tT__rtle
TYPE -OF FACILITY : t�PSirCl
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r V
,F NDINGS - -
- ^ ��1! .
VIA
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4t1V'
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If
:Y
9
P
Sipature-and. Title _
_
T acknowledge receipt of this report SIGNATURE;
�02/96 � � -�° �.�� . � , r T
Title: