Full Text
CORTLAND COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH COUNTY OFFICE BUILDING, ROOM 120 60 CENTRAL AVENUE CORTLAND, NEW YORK 13045 TELEPHONE: [PHONE REDACTED] FAX: [PHONE REDACTED] APPLICATION FOR PERMIT TO CONSTRUCT A WATER WELL MAILING CITY, STATE, ZIP PROPERTY LOCATIONS TAX MAP TO BE PURPOSE OF WELL: (CIRCLE ONE) DRINKING WATER, INDUSTRIAL, PROPOSED CONSTRUCTION INFORMATION DRILLING NYS DEC WELL DRILLER REGISTRATION DESIRED WELL YIELD:___5___ 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 to Please attach a site plan which includes separation distances from property structures and potential sources of contamination (may use survey maps or tax maps). 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. *****OFFICIAL USE ONLY***** Permit issuance approved If permit denied, Date Permit 05/00 J:\Environmental\Environm\WPDATA\water\privatewater\Forms\PermitWell.doc