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03472
® PUTNAM COUNTY DEPARTMENT OF HEALTH /
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print or typeCr7�`[t
Well Location
Street Address: Town/Village: Tax Map #
pX Block�Lot(s)
Well Owner:
Name:
Addre s: 5�9
P n #:
Ile
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 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
for Drilling
Well T e
rilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ...:........................... Yes _ No C .
Is well located in a realty subdivision? ........................................... ............................... Yes _ Nom
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available on site? ........................................ ............................... Yes _ No
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:
I .
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 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 alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam ounty.
Date of Issue -! �° Pe[m'itls ing O, icial:
Date -of Expiration Title:
Permit is Non -Trans
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
RECD S E P 14 2010 Rev. 3/06 .
%i
11/24/2008 21:48
a
19737646404 ALLCOUNTY
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Name A Relationship
DATE
PROPOSED
ADDRESS
PAGE 02/02
KCS i'a[a &L PCHD COMPLAINT# ,
PHONE 9bo - to 1%
REGISTRATION /LICENSE g 49 C
Pmm
eel (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nahirr3 anti "tmnt of the ramir
I, as owner,agree to th ditto s on! . form ,
SIGNATURE � TITLE bCv4;'- DATE ZJ 2
(owner)
I, the septic in§$elW, agree to ply mNip conditions of this permit for the septic system repair
SIGNATflJ TITLE f ^a_ ! DATE
Propogal. a2pMyX9 wilt the follQl*g ccada ona:
I. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch by the septic system instaner whin 30 days of the repair, in duplicate showing:
a. Owners name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, ate.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best ftt design and there is no guarantee to the duration so which the
completed SSTS repair will function.
5. No completed work is to bepackfilled until authorization to do so has been obtained from the Department,
Is
COPIES: PCHD, Owner; Installer
PC -RP 99ML
Proposal Denied <
�S
Dat
tplicable odes Yes ;/ 5
.s'
ExpIGR Date
Nos
Rev -2/07
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