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CD ® PUTNAM COUNTY DEPARTMENT OF HEALTH
0 DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION'TO'CONSTRUCT A WATER' WELL f
please print or type
0I MUSEUM
Well Location
S et Address: TownNillage: Tax Map #
L �,(IAap/ Block Lot(s)
Well Owner:
Name: 00664 r
Address.
Phone #.
Use of Well:
Residential _Public Supply Air /cond /heat pump _Irrigation
1- Primary
Business Farm Test/monitoring j,--Other(specify)
2- Secondary
Industrial Institutional Standby . &/( ,4124.46GuA
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) Deepen Existing Well
Detailed Reason
for Drilling
4-OD f Qr o..ble e I h • c� ' Ica: e ,/
p SJ fit' (A, 04. _ C o We I(
k'r Wwfie
Well Type
rilled Driven Gr vel 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: D " w c.r. , '-A" Address:_ /,<-,I )g a v- a oe -,St & -A ¢. � fil14 p
Is Public Water Supply available on site? .......... ............................... ... Yes _ N.qr-
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: //0 _ _.. Applicant Signature�M/hlah�
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.
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 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 County.
Date of Issue 7 �`� Permit Issui
Date -of Expiration Title:
Permit is Non- Transf rable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
80 " 0� C 0. "Iis rev re Rev. 3/06
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