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02594
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APP.LICATIO.N TO,,CONSTRUCT. -A WATER.WEU,, " .//
please print or type PCHD Permit # s� l?— 0
Well.Location:
Street Address: Town/Village Tax Grid #
Jy do S'C a.' Map Block Lot(s)
Well Owner:
Name:
Address:
w,l b
oa
Use of Well:
�/ Residential 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 gpm # People Served Est. of Daily Usage _gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
s s' ei! s J 'r MoJuce 1r kbu wtxl P r
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 i,,-'
Name of subdivision Lot No.
Water Well Contractor: -M.4ij ; ,t/4pv -s-e Address: 1XZ 64!ni er
,po:
Is Public Water Supply available to site. ........._I Yes . No . r/
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to b provided on separate s t/plan.
Date: i v - '' o Z Applicant Signature: -c
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 16 -of thi ', -,: �_`
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code anrovdddd_-
that within thirty (30) days of the completion of water well construction, the applicant or their desgnatd4 o
S;
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with 6i=;
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on Ron E4
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 t r well driller certified by Putnam
County. / ,, ..,1
Date of Issue Z_-- Permit
Date of Expiration / ,�: -o Title: _
Permit is Non- Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copJJOwner; Orange copy - Well driller
Form WP -97
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80. 3 AC, CAL.
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80. 73 AC. CAL.
I acknowledge receipt of this report ' SIGNATURE;
02/96 Title; _
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Sheet L of
PUTNAM :COUNTY DEPARTMENT OF-HEALT-1I
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FIELD ACTIVITY REPO <
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Street
Town Stat
Zip
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PERSON IN CHARGE
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Harp_
Name and Title ..
TYPE OF FACILITY ; .
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FINDINGS: ---
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Signature and Title
I acknowledge receipt of this report ' SIGNATURE;
02/96 Title; _