HomeMy WebLinkAbout2624DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
52. -3 -9
BOX 22
02624
KIM
L
or;
■
IL
T
1'
NIL 0
,1
02624
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
HD .
please print or type PC Permit #
Well Location:
Street Address: Town/Village Tax Grid #
/ 5 e / A �' ✓�� / `/e��y Map `S3
Block Lot(s)
Well Owner:
Name:
Address:
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 _ _�5 gpm # People Served 3 -S— Est. of Daily Usage o _gal.
Reason for
Replace Existing Supply Test/Observation
Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
-o�, - r s
for Drilling
rv��
Well Type
Drilled Driven Gravel
Other
Is well site subject to flooding? ............. :..................................................................
Yes No
Is well located in a realty subdivision? ..................:................... ...............................
Yes No dG
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.
Date;:. r 9 ^_. Applicant.Signattu
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 Permi
Date of Expiration Title:
Permit is Non - Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
—S
MIA
F? .4-7-
5 7'W
193.541
Lz 4 6.4 6 LPSet
Ret
W . . . . . . . .
S'Ty:
F R. R Et§%
�01
Q
COUR r
U)
Ln
BLo CK
L F?
e t.
Ly
�c
0 PA C EL /3
Ac.
I-P Set
PARCEL
BY CERTIFY TO
ABSTRA�T LTD.
GUARANTEE Co.
i
iS ACCURA6 ANn r. . nPprr,,r
SCALE: 1 = 30
it
F%_
GA
SURVEY FOR
STE ART
ME
334.3 J..
SURVEY FOR
STE ART
ME