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BOX 36
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04796
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PUTNAM COUNTY DEPARTMENT OF HEALTH
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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pleuse print or type
APPLICATION TO CONSTRUCT A WATER WELL .
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Well Location
Street Address: TownNillage: Tax Map #
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y Vv 0i ri 0`T 6,1 L�: f l
ap Block Lot(s) .
Well Owner:
Name:
Address:
Phone #:
Use of Well:
Residential _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.
VP Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
r7 G G -- Q ".
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _ Nom
Is well located in a realty subdivision? ........:.................................. ............................... Yes No_,,.<_
Name of subdivision Lot No.
_
Water Well Contractor: `1 ri�'1($.f1 Address: 1 5 Z�t�,B''
- r- e
. _ ... _.
Is Public Water Supply available on site? .................................:::... ............................... es No�:
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/
Date:[06y'° _.. Appiiant Signature:_,
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 Departmel
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 °23 / % Permit Issuing 0 c
Date -of Expiration Title:
Permit is Non
White copy - HD file; Yellow copy - Building Inspector; Pink copy.- Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06