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HomeMy WebLinkAbout4359DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2-4 BOX 33 04359 I,yti ' %L i ., ! . � , Jr. , r' L ' L he it �' '' ` t �' ��, , 04359 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL pleak'printprt3pee =, ,.._ , t .. PCHD Permit # Well Location: Street Address: Town/Vi}lage' Tax Grid # AIIl.L v5-'7)' Z7- 1044>1-,4,41 V! Map 0# Block 2 Lots) Well Owner: Name: 3,7 iUZ0r0N Address: AM 129A0 604A S7 4-4-01;w Qr4M r40 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 - 4 5pgal. Reason for Replace Existing Supply __,?kI'est/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason _KI for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes —X No Name of subdivision 6p94zy,(3 niu// � Lot No. 1_ Water Well Contractor: Pk. �f�.� -�f !ti,S Address: � ltlf° Is Public Water Supply available to site? ................................ ......Late es No � Name of Public Water Supply: �ji Distance to property from nearest water main Proposed well locati n & sources of contami o be provide pp an. Date: Q t? / Applicant Signature: �... , PERMIT TO CONSTR CT A WATE 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 ater well driller certified by Putnam County. / . /f , A, . Date of Issue 10 -V7 -401 Permit Date of Expiration - Al -o m Title: _ Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; grange copy - Well driller Form WP -97 0Sg IV PUTNAM (COUNTY DEPARTMENT OF HEALTH DMSEON OF ENVMRONMEN ICAL HEALTH S ERW CES APPLICATION TO CONSTRUCT A WATER WELL ,p J - - .:�►ease..prinrJOr type: - _ PCHD Pea��:�## -- �.U, - °� WeU Location: Street Address: Town/Yfttap Tax Grid # ,a-'5* , Map of Block '7, Lot(s) Well Owner: Name: 37 GBoTV-fJ Address: /2v4o G'a N ®SS(Nia.) �v ! ® .GZ Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation II- p>rimairy Business Farm Test/Monitoring Other (specify) 2- secondairy Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason �51®Q,r*t, &LA., i for DriMng 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. 2 Water Well Contractor: &At 4 56R1< Address: PVM14M WE . 149 5'P r7Z Is Public Water Supply available to site? .... ................ .................. Yes No Name of Public Water Supply: `, illage �. Distance to property from nearest water main �v Proposed well location & sources of contami n' be provid on 'eparate sheet/plan. Date: 1 ®9 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 well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. YOR 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 w er well driller certified by Putnam County. I h 1-f- It Date of Issue 10-12-01 Permit Issuing Date of Expiration /(p 12 -D 3 Title: Permit As lion- Transf n>re able — White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 M/