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CORTLAND COUNTY HEALTH DEPARTMENT COUNTY OFFICE BUILDING Nicole Anjeski, MS, MPH 60 CENTRAL AVENUE Public Health Director CORTLAND, NEW YORK 13045-2746 Lisa Perfetti, BSN, RN (607) 753-5036 Deputy Public Health Director FAX: (607) 753-5209 Ngozi Mezu-Patel, MD http://www.cortland-co.org/432/Health-Department Medical Advisor Division of Environmental Health Donald Ware; Environmental Health Director [EMAIL REDACTED] WORKING TO BUILD A HEALTHY COMMUNITY SINCE 1929 APPLICATION FOR PERMIT TO CONSTRUCT A WATER WELL MAILING CITY, STATE, ZIP E-MAIL PROPERTY LOCATIONS PROPERTY ADDRESS: TAX MAP STRUCTURE TO BE PURPOSE OF WELL: DRINKING WATER, INDUSTRIAL, AGRICULTURAL, OTHER- PLEASE CHECK: _____Replacement well New well Accompanies a septic application PROPOSED CONSTRUCTION INFORMATION DRILLING NYS DEC WELL DRILLER REGISTRATION DESIRED WELL YIELD: GPM WELL DIAMETER:___6 inches___ CASING MATERIAL:__steel_____ Is the area subject to flooding or heavy surface Distance to potential sources of groundwater Type(s) of Is public water available to the property? Distance to Property lot size: A site plan must be submitted which includes separation distances from property structures and potential sources of contamination (may use survey maps or tax maps), or show on septic design. I DO CERTIFY AND AFFIRM that all construction and completed works pertaining to this water well system will be in accordance with the requirements set forth in Article XII of the Cortland County Sanitary Code, “Rural Water Supply”, Subpart 5-2 of the New York State Sanitary Code, and the “Procedures for Water Well Construction” of the Cortland County Department of Health. See fee schedule on website for appropriate fee and make check payable to: Cortland County Treasurer *****OFFICIAL USE ONLY***** Permit issuance approved If permit denied, Date Permit J:\Environmental\Environm\WPDATA\water\privatewater\Forms\applicationl.doc SIGN