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BOX 31
04112
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04112
C� 3 PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL.
PCHD Permit # [ C
please print or type
Well Location: S
Street Address: Town/Village /f Tax Grid #
o i, L Ad " g1,,k1 V el Map Block Lot(s)
Well Owner: N
Name: A
Address. /� n r J
J- Se Z
cc
Use of Well: e
esidential Public Supply Air /Cond/Heat Pump Irrigation
1- primary B
Business Farm Test/Monitoring Other (specify)
2- secondary I
Industrial Institutional Standby
Amount of Use . Y
Yield Sought gpm # People Served Est. of Daily Usage gal.
Reason for R
Replace Existing Supply Test/Observation Additional Supply
Drilling N
New Supply (new dwelling) a/beepen Existing Well
Detailed Reason L
L r
r
for Drilling r
Well Type U
UiTdlled Driven I Gravel Other
Is well site subject to flooding? ...................................:............. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes N
Name of subdivision Lot No.
Water Well Contractor: Of k4 Address: 4 a-i
Is Public Water Supply available to site? ................................... ............................... Yes No L-,l
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: ld 10� D -7 Applicant Signature:. -
- +
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 �J
well drilling operations be contained on this property and in such a manner as not to degrade or otherwrge _z
contaminate surface or groundwater. ° .
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless,'o ff; ==
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may bey:'
amended or modified when considered necessary by the Public Health Director. Any revision or alteralon
of the approved plan requires a new permit. Well to be construcDby ater well driller cert' ed by�utn o County. Date of Issue Permit Issui '
Date of Expiration .O Title:
Permit is Non - Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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