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HomeMy WebLinkAbout3325DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -1 -82 BOX 27 41 1 . d: 1,4, ' ��, 116 61 -1 L T, or f 03325 � o 19168 3y5 -o4� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL ~ please print or type Ci Q , - A.4 Well Location Street Address: Town/Village: Tax Map # 41 , J Map Block Lot(s) Well Owner: Name: Address: Phone #: &4 e, J VqA '�i' e4 �4*' 00L� 16� Use of Well: yResidential Public Supply Airlcondlheat 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 gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason 6" 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: d' fsa-' T Address: � (tea VIc" Imo` Is Public Water Supply available on site? ....................................... ............................... Yes _ No Name of Public Water Supply: Town/V illage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on se . to sheet/plan. j. Ann-Iicant Signatura:�- 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 Countv Health Departmei 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 alter i of. he approved plan requires a new permit. Well to be, constructed by a water well driller certified by Putnam Co, t 2Z G� Date of Issue l✓� Permit Iss Offic I:. Al Date -of Expiration / Title: Permit is Non- Transfe able t White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06