Loading...
HomeMy WebLinkAbout4774DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26 -1 -86 BOX 36 1 1 r f !1 -.1 1 11 Per 1 1 W67W'l fir" -' A. . -rr �. 6 q�� L ,, a � �QS 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