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HomeMy WebLinkAbout2122DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 45. -4 -5 BOX 18 02122 . ..E .R , . ... 02122 DEC -20 -2000 10:00 FROM:BOYD ARTESIAN WELL C 845 2258420 TO:92787921 P:2/2 nr PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION-3-0 CONSTRUCT A WAXER WELL ° . •• >: a a .� .....:..... please print or type . PCHD Permit Well Location: Street Address: Town/Vi.11a�ge Tax Grid # '-f`I'mm"Z w a. [A y ^'S ov Aeas�l Ma Block tot(q) Well Owner: Name- Address; Lov' + 1-ma-W4140pa c Use of Well: _ Resi al Public Supply Air /CornUHeat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought � gpm # People Served C Est. of Daily UsagcS2 Reason for Replace Existing Supply Test/Obscrvation. Additional Supply Drilling New Supply (new dwelling) Dccpen Existing Well Detailed Reason't,{� for DriWng Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................ ...1........................... Yes No Is well located in a realty subdivision? ........................................ ............................ Yes No Name of subdivision Lot No.W Water Well Contractor: Address: Is Public Water Supply available to site? .... .......................: .......................... Yes No Name of Public Water Supply: TownNillage Distance to property from nearest water maim Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: la ---do -uQ Applicant Si". nf of 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 S 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 % l� Permit issuing Offi ial: Date of of Expiration / Title: f-7- e Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP 97 utC- dO- ebad.10 :00 FROM:BOYD ARTESIAN WELL G 845 2258420 70:92787921 P:1/d -6., Boyd Artesian Well Co., Inc. ---- _ --- R.D. No. 5 Rte. 52 . . Carmel, N.Y 10512 (914) 225 -3196 (914) 225 -8420 FAX DATE. TO: FAX: Xle - 7C12 i RE: —� - PAGE I OF ', COMMWS: o� c This trammission is tnrended only for the use of the indhiduai or enoty to whtch it is addressed and may contain tnfonwrion rhat is pewleged . evafldential, and exempt from drsctosure under applicable few. !f the Header of this message !s nor the intended recipient. )m are hereby notified that any dissemination, &nribupon, or c»pying of this comnru »tcaMon is $Maly prohibited If you have received this communication In error, please remm the original to the sender by mail..