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04359
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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/