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Home My WebLink About2721DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -2 -39 BOX 23 a Elm olieli T if .;II IN Ll I I F�Jrjo. rj. I� 1' 02721 PUTNAM COUNTY DEPARTMENT OF HEALTH i ® DIVISION OF ENVIRONMENTAL HEALTH SERVICES - ..., .+.- ......,,,..- :..__�.... ...,._ . APPLICATION TO CONSTRUCT A WATER WELL please print or type Well Location Street Address: TownNillage: Tax Map # 1 Ja L G hD 4� 'Jc�ow 1 k11 I �4 11P Map Block Lot(s) Well Owner: Name: k� �.v;[sc�� Nlar�c�IS Address: ll��r e D L p� Jd �ano�uLr /f�lloW nrJ[ IW l 441k _1ial Phone #: 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 Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason G-(( ay- o6m. 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 Name,of subdivision Lot No. Water Well Contractor: V k 'ersd W Address: l'X�r �y Is Public Water Supply available on 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: 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 DeDartmet 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 Countv. Date of Issue D g hq Date -of Expiration Permit is Non -Trans era le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 4 e. i DEPARTMENT OF HEALTH Division of Environmental Health Services ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 .... _.. . - -r+- .. -- ��•O- -'w -^'^ . -. .r +al. v_: ., � -- _.v .a.r• «a.r� .Z_s...- y- .._... w.. : -..- v�. APPLICATION TO CONSTRUCT A WATER WELL p /a(�7 PCHD PERMIT # b IS WELL SITE SUBJECT TO FLOODING? YES _ L NO IF TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1�0 -'/v HAM OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY TO "PROPERff- FROM - WEARES'Ti- WATER`KAIN LOCATION SKET SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signature) `1 "V �•i �, ^j i 77 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one.water well as set forth above is of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, thirty (30) days of the completion of water well construction, 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements Department attached to this permit. granted under the pra�is3�ris and provided that wfthiQ_�') r the applicant shah`? - :J < Z_j Uj of the Putnam County Health 3 Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well dr' ng operations be contained on this .property and in suc7/f a manner as not to de ade or se con inate surface or groundwater. ?ate of Issue• 19 i ite of t /irmit 1 9 Expiration 19 P it Issuing Official is Non - Transferable White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller ddre To Vi e t Tax Grid Number WELL LOCATION ��tree N e bail' g res ,'Private' WELL OWNER 0 Public USE OF WELL *RESIDENTIAL ® PUBLIC SUPPL IIJ Q Alel COND /HEAT PUMP ® ABANDONED 1 - primary ® BUSINESS ® FARM ❑ TEST /OBSERVATION O OTHER (specify 2 - secondary ® INDUSTRIAL C3 INSTITUTIONAL ❑ STAND -BY AMOUNT OF USE YIELD SOUGHT PEOPLE SERVED- --- --/EST. OF DAILY. USAGE al XkEPLACE EXISTING SUPPLY ® TEST /OBSERVATION G ADDITIONAL SUPPLY 1REAS0N FOR DRILLING p NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL DETAILED, REASON FOR DRILLING WELL TYPE DRILLED ®DRIVEN []DUG O GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES _ L NO IF TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1�0 -'/v HAM OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY TO "PROPERff- FROM - WEARES'Ti- WATER`KAIN LOCATION SKET SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signature) `1 "V �•i �, ^j i 77 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one.water well as set forth above is of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, thirty (30) days of the completion of water well construction, 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements Department attached to this permit. granted under the pra�is3�ris and provided that wfthiQ_�') r the applicant shah`? - :J < Z_j Uj of the Putnam County Health 3 Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well dr' ng operations be contained on this .property and in suc7/f a manner as not to de ade or se con inate surface or groundwater. ?ate of Issue• 19 i ite of t /irmit 1 9 Expiration 19 P it Issuing Official is Non - Transferable White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller yid � ��.. \ .. �• ° °.ap, air � 10 tj °.I' uj tj �V _...rte..._. N � / // � • � ( I 4 a� a 3 to u o ' r RECEIVED. . U 10, t'U i!' M CUUl�ITY a ` C fv `�• r S I� to J ,Ny H.• 1� rb ° I I N 'J -..rool N u� 0 h u / 7I ` 5Q � d N� �3 u�IL v �+� 4 2.'0 IJIFr r. km SSjYoc. 1L 0- - vo-S Aj. 1-7 0---! 1 C) za 9 Woe 7. C- 4" pcjs 14 OL ;rF-W- A" 0 To C.MMO, 41FA--r" LAUD LO C/3 Fib 7 c. M A-rrN c\/ I L L E tJ of, pur&jA>A VAL-&-r—Y' P 1) T &JA Y-' 7