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03662
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
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Well Location:
Street Address: Town/Village/� Tax Grid #
`b &� -7ew O U ' Map �71,l YBlock Lot(s) P-$
Well Owner:
Name:
Address: I ? CC -WI&7= �-
r640,11 �'� �r�a
Im A, oto 4•c I ouy ( o-sx-, (
Use of Well:
I 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 __�r_ gpm # People Served I Est. of Daily Usage Sao gal.
Reason for
X Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
v- W,LI
for Drilling
Well Type
X Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realg subdivision? ........ ........................ ............................... Yes No
i
Name of subdivision N c_k_Nay k..`S
. Lot No. S
Water Well Contractor: Address:
Is Public Water Supply available to site? .................................. ............................... Yes No .x
Name of Public Water Supply: L11A Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to ovided on separate sheet/plan.
Date: Y v7 lev Applicant Signature: / ` W
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 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 Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water wel driller certified by Putnam
County.
Date of Issue 00/ 7 �O Permit Iss in Official
Date of Expirati dn Title:
Permit is Non- Transfe ra le
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Fonn WP -97
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MAP OF SURVEY
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TOWN OF gllll .91,w V,gLLEY
#es 60 ,oe.»f. COUNTY OF D4/TN,9M
�a: ✓�rnen NEW YORK.
Scale: .1 In. = S0 Ft. /t�JCII� /� 1962
c,.
Q 1 certi f )' that this map was made from an actual
survey of the property.
Surrey completed on j174y /Z , 1962
�-Z , Map com.plcted nn /YJpU /G 1962
• --� �; / �� �� s e� � /vie Z2 , i �3
pd 1 Certified to:
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G
�\ ROY BURG SS
'D �
Professional Engineer & Land Surveyor
,C %d Ala N° go7\ License No. 985. Carmel, N. Y.