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HomeMy WebLinkAbout1918DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.23 -1 -8 BOX 17 .' J rliL. � k . ko%. Ir ` . J . ' III- ' T ... 1.6 �'r 11 1., I'� i I ILij 01918 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL Well Location: Well Owner: Well Type: Depth Data: Use of Well: 1- primary 2- secondary Water Well Contractor: Reason For Abandonment: please print or type Street Address: Drilled Well Depth {/v ft i� Residential Business Industrial Name: W'.42 PCHD PERMIT # wnN'lla e Grid # Map Bloc T Lot(s) Address: Driven Dug Static Water Level Public Supply Farm Institutional Other ft jDate Measured Air /Cond/Heat Pump Abandoned Test/Observation Other (specify) Standby /oyia � A Description of Work To Be Performed: —/4/1//— G Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH - o DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type I W, INT. ME WIN i. �I Well Location Street Address: Towge: /P� Tax Map #� Map Block Lot(s) Well Owner: Name: Ad ress: Phone #: Use of Well: _Residential Public Supply _ Air/ and /heat p p_irrigation 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 gal. _Replace Existing Supply Test/Observation _ Additional Supply Reason for Drillin New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ...................................................:... ............................... Yes _ NoX,_ Is well located in a realty subdivision? ........................................... ............................... Yes Nom Name of subdivision Lot No. Water Well Contractor 4 & /,0a gt&:,.� /'/, &W Address: .� Is Public Water Supply available on site? ....................................... . ............ .................... Yes_ - o,"_ 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. Date;.. _: Applicant Signature: r. 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 Departmet 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 Commissioner of Health. 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. i Date of Issue Permit Issuing Date -of Expiration v Title: ( 2 Permit is Non-Transfer/able White copy - HD file; Yellow copy - Building Inspector.; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 ct+-) Ad �Nv Boyd -Ar it, is 10 =5`4 10512 :(845)'225 Fax, (84.55).. J 0 7S ........,.Boyd Artesian WeffCo,0 Inca 1054 Rte. 52 Carmel, N.Y. 10512 (845) 225 -3196 Fax (845) 225 -8420 - avct,n