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BOX 35
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Street Address:
Town/Village: Tax M701ock a p #
0-SC-r4_
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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
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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
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