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HomeMy WebLinkAbout3065DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.26 -1 -20 BOX 25 9 also ON ,; , no _L , •T all a 16 r m: ,. , ` L ILL .. r 03065 PUTNAM COUNTY DEPARTMENT OF HEALTH V �� DIVISION OF ENVIRONMENTAL HEALTH SERVICES � e s q3 - - • -A P_PI.,I A TI N TQ_ CO . CTR.UC�'..A_, WA'll'�11�:��E><, .v.2 X. X a t . .... � a•�,:. .. .n.T ..v +.��.._.. _ ;^>4 —•-sew .z- "4 _ rna:'_+ -•v ... •i'. .... •.1..yp•..y. �.>. ,. •. ,�....s� '�j�y/a� �� A� t. please print or type PCHD Permit # Well Loeation: Street Ad s: T nNillage Tax Grid # Map Block Lot(s) Well Owner: Name: Address: X33 4�I-zas'79 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 _J_ gpm # People Served Est. of Daily Usage s dal. Reason for OL Replace Existing Supply Test/Obseivation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? > .................................................. ............................... Yes No Is well located in a realty subdivision? ....., e� . ......................... ............................... Yes No Name of subdivision' Lot No. Water Well Contracto'rl_ t� Address: Is Public Water Supply available to site? ................... .0 ... ...::...... ........:........... Yes No Name of Public Water Supply: Town llage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. /Applicant Cigr!ature: %J 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 suchar anner 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,4�? amended or modified when considered necessary by the Public Health Director. Any revision ojj, e ation r " of the approved plan requires a new permit. Well to be constructed by a water well driller certif ed=by­PutnamI County. Date of Issue 5 &ens Permit Issuing Official Date of Expiration '��v/ Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form a a..h`�• yta..� �cr.�..