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BOX 25
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03065
PUTNAM COUNTY DEPARTMENT OF HEALTH V ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES � e
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- - • -A P_PI.,I A TI N TQ_ CO . CTR.UC�'..A_, WA'll'�11�:��E><, .v.2 X. X
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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
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