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PUTNAM COUNTY DEPARTMENT OF HEALTH
ROE, DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print or type ?CIIQ>1 _'r ss
Well Location
Street Address: Town/Village: Tax Map #
Q is Qlap Block L2 (s)
owk*4
Well Owner:
Name: ?,_
Address:
Phone #:
Use of Well:
V7esidential _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 gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drillin
New Supply (new dwelling) Deepen Existing Well .
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Iswell site subject to flooding? ....................................................... ............................... Yes — No_l.--,_
Is well located in a realty subdivision? ........................................... ............................... Yes No r
Name of subdivision Lot No.
Water Well Contractor: Address: Y d 24 t, 0 (/
Is Public Water Supply available on site? ....................................... ................:.............. es _ No_A..
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 sheetlplan.
_.
Date _Applicant S1' nat6r —
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 Departmer
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 9�i71�S- Permit JAs4ing Official :��
Date -of Expiration 5,/17 /17 Title:
Permit is Non - Transferable
White copy HD file; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller..
Form WP -97
Rev. 3/06