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OWNER'S NAME L5[ y l 6 I J o is (-Go PHONE �L� ^ �c7 � Z
SITE LOCATION W(C fC- f- d5*MTr 24# 9�
MAILING ADDRESS t- &-4e r d 0 9'3)
PERSON INTERVIEWED PaM Canplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE 10 (W Ci 3 TYPE FACILITY
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Ccc#C�Y
PHONE ' ; : ? `vl S
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
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Proposal appr / Proposal Disapproved
ture & Title
to
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE `' TITLE DATE t Ozi bzg-?
PUS: V&be (PAID); )Wlcw Mkin ED; Pink Onlicant) i
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL 1 :n n.
please print or type PCH'DPermlt#
Well Location
Street Address: Town/Village: Tax Map #
Va
�;r.DP4 �C5: t`�j�
:� rs . �! �J0, Xo ,f rya, Ma� Block Lot(s)
Well Owner:
Name:
Address:
Phone M
>" -0- LA* �
�°l ke � ® r 1,
eA A
�, ea �q k1 > .
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 Drillin
New Supply (new dwelling) '--beepen Existing Well
Detailed Reason
�,, r elt k/e, l n �,� g ( , :_ -a 't �-- .yam W '( 7 1".
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: n dtr' ..7- Address: a 511 *%e- CT �° a we (lg
Is Public Water Supply available on site? ....................................... ............................... Yes _ No
Name of Public Water Supply: AJ I& Town/Village N /.-
Distance to property from nearest water main: /V
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date :.._ : l /j ... Uy . :_. ..' ... Applicant Signature-Al < Aadn
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.
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.
e'
APPROVED FOR CONSTRUCTION: This approval expires years from1he 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 Putn unty, -�
Date of Issue Permit I
Date of Expiration Title:_
Permit is Non- Transfe able
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06