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HomeMy WebLinkAbout4676DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.08 -1 -1 BOX 35 1 rom - I I' 1 1111 # I i� ' - ' L, ' ' ,'L .�' r '•,�, ' mom ~, IN , Amb K r , �. 6 1 W $3 Street Address: Town/Village: Tax M701ock a p # 0-SC-r4_ f 1 R Akkstm, Vw I l W Q h Map Lot(s) PUTNAM COUNTY DEPARTMENT OF HEALTH Name: JD KC, I b Address: h ; � DIVISION OF ENVIRONMENTAL HEALTH SERVICES Pyw�Ay. . ,. _ ,ja. 'r 1..4 ... -' Q r1. -•. :1 yj •, - � ... :J �`�`��.Frr. w��iYi •� ! ..V- .,\tirA t1•- V � •r.• -.fir ... I.. � We6l'A d rl /4 14 � It e q94 — 3 1 133 Use of Well: APPLICATION TO CONSTRUCT A WATER WELL please print or type MA PCHD� Permits �' x'�� �t�'',�r�" Well Location Street Address: Town/Village: Tax M701ock a p # 0-SC-r4_ f 1 R Akkstm, Vw I l W Q h Map Lot(s) Well Owner: Name: JD KC, I b Address: h ; � Phone #: e- M We6l'A d rl /4 14 � It e q94 — 3 1 133 Use of Well: Res dential _Public Supply Air /cond /heat pump_lrrigation 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 Drilling New Supply (new dwelling) L- eepen Existing Well Detailed Reason 7 Ig gn. rd p li C& Vv 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 Water Well Contractor: vv Lot N 2. 04 Address: 1 S Z g r e r �7'-041&4 Is Public Water Supply available on site? ....................................... ............................... es _ No w Cf /e• Name of Public Water Supply: _ Town/Village Distance to property from nearest water main: - Proposed well location & sources of contamination to be provided oMsearate sheet/plan. SC u1 QW 6d /( k4 C--c elk .. -..., ... . 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 Departmei 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+ae 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 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 Putnam Co nty. Date of Issue � Permit Issui cial: Date of Expiration Jill Sibs Title: Le L c ' Permit is Non- Transf ra le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 Y• h