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HomeMy WebLinkAbout2836DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.10 -1 -18 BOX 24 ,I ` or- IN No No Mi Pon No No J I I Ir r 'T. ' ,` ,♦`' f,' , ' N' No . IN -'e�, I , ,1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLIC T APPLICATION TO CONSTRUCT A WA WELL CONS ER T r � T fAe ��R ciPtllf .1P .,`yili�4 PC - 1 , Penrit. #. Well Location: Street Address: e Tax Grid # ,rT�own/Vill1a 2.30W - J/fo2a QR 1 u-7rvm,1 VALZE,y Map Block Lot(s) Well Owner: Name: Address: JAMe-S GoRoatJ I SA r10 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 /S- 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 for Drilling Well Type x Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes No n Name of subdivision Lot No. Water Well Contractor: N or?m h N �9 A, o ir ezS o ^j Address: - 8 n rz &e ms 7 %. uri c c.�r Is Public Water Supply available to site? .................................. ............................... Yes No A\' 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: ,10 1 0 -4-- Applicant Signature: t PERMIT TO C NSTRUCT 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 driller certified by Putnam County. , Date of Issue 110 L O ?— Permit Issuing -Wpial: Date of Expiration ' Cf l y / 0 Z Title: Permit is Non- TransferrEabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 . a `w ryry wV .r IV rt �r�dM N1;�O «:r'^� N7y0� w j , e a �syb 000,�4 I � rMS I / d 9 � / 0o sf i %x'10 YgA07 J,7y3FWjvoj y • .� �V C