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04559
�4 PUTNAM COUNTY DEPARTMENT OF HEALTH
w ` DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1�yS�3
3 is
APPLICATION TO CONSTRUCT A WATER WELL j j 7746o
Giese R�nc of ryge . I : ....PCHD Ferret
Well Location:
Street Address: To illa a Tax Grid #
5Il
Map lock % Lot(s) S�3
Well Owner:
o Kie :
Address:
Use of Well:
�4 Residential Public Supply
Air /Cond/Heat Pump Irrigati
1- primary
Business Farm
Test/Monitoring Other (specify)
1-secondary
Industrial Institutional
Standby
Amount of Use
Yield Sought gpm # People Served Est. of Daily Usage _______gal.
Reason for
Replace Existing Supply
Test/Observation Additional Supply
Drilling
New Supply (new dwelling)
eepen Existing Well
Detailed Reason
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:
Address: /� Y
Is Public Water Supply available to site? .................................. ............................... Yes No k'
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: a Applicant Signature:
n^-
---T----
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 well driller certified by Putnam
County.
Date of Issue d� Permit Iss ' fficial; lr,
Date of Expiration Title: 1,
Permit is Non-Transferrabli
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
. #f-7y
,I .. --i I
Dean No4man:.
The 6ottowing in otmation.is 6,tom my town tax bitt:
SWIS:372800 SIOL 85.5-1-53
Add4e44: 15 Sptit Rock Road
Putnam Vattey, New Yo4k
I Family Res. Rott Sec .1
P,%ope,%ty De4ctiption 85.5-1-53
Acct # 253315
I.think this is what you need 6o& the pe4mit 6o4 4ed4itt.
I can be peached at 845-528-7860.
Hope to see you soon.
Since,% y,
e
Theresa Cavioto