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