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HomeMy WebLinkAbout1571DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -5 -4 BOX 15 rtrm IL Er � - 01571 J, SITE d P _ i9.S— i/ PERSON INTMVIBQED PCHD Ccaplaint 0, Dame & Relationship U.e, owner tenant, etc.) r7 //7 / r7 / TYPE FACILM • -�� � °�. DID 1' �. �' .. ��� Proposal (include sketch locating all adjacent wells): NoTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered arc hitecto ` _ ., Proposal approved >�,- Proposal Disapproved �z �/l roposal approved with the following conditions: to Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street fie, Town and Tax Map number. co Nation of installed components tied to two fixed paints (e.go,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diem. x 61 deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be perform in accordance with the above proposal and conditions. as SIGNATURE %/ :. �: / /1�. , 1 OM 7Z .�• x.: �� - i.:. a :I; .. 1 � SITE 2 -aia - 7M$ MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # j %p Name & Relationship U.e, owner,tenant, etc.) DATE 7//.x/13 - - -- TYPE FACILITY Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. Proposal approved Proposal Disapproved 5 Inspector's Signature & Ti with the following condi 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of-owner agree to the above conditions. SIGNATURE TITLE DATE 3W: Wzite MD); YeUcw Mkin HE); Pink (ARIiamt) PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION Y C' (0 t _1 I `�- 1 OWNER'S NAME 2 +' MAILING ADDRESS U(D OFFICIAL USE ONLY 3 -O TM# 3 q • v S7' q PERSON INTERVIEWED 4 i4) J) :Q . PCHD Complaint # LtAl �- �I��ame��ReTationsFip i.e., owner, tenant, etc. t DATE 11T a Lo � TYPE FACILITY I^es%,dv��`�.�Q PROPOSED INSTALLER S-2A PHONE ADDRESS REGISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. ev,ontir ! W1.11 � ,14n CA9 /c4i1 A I/AQ91k, -'--I-,-as owner; orTeported agent of owner agree to the conditions stated on this form:-- - SIGNATURE TITLE (-'4AfIA QA DATE 1 % Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Q� Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DA f3u -ll�fi �°�� asb3 NY. �.. . r-n xa �ERIat ed c-Lry_weil _ V. 30' -- SITE LOGATIOE MT cJ 7• � � J' PERSM MERVIMM 0 W K Elr Pty Caup].asint Relationship (ioe, owner,tenant, etc.) DATE -7 TYPE FACILITY PROPOSED INSTALLER 12 U) A PPe PH= 91 7T Y3, REGISTRATION # (include sketch looting all adjacent walls): ZME: Repair must be in same location and of same type as original sewage disposal systw. Different location may require submittal of proposal from licensed professional engineer or registered architect. C- Proposal approved Proposal Disapproved Inspector's Signature Title Dqxe 30 0 cats showing: as Owner °s nwmeo - b, Site Stmt Name, Tbwn and Tax map number, ca Location of installed camponents tied to two fused points do System description (e.g., 1250 gala concrete septic tank, drywalls surrounded by one foot + gravel) eo Installer's name and number. (e.g.phouse corners). three precut 61 diam. x 61 dsap System repair to be performed in accordance with the above propel and conditicnso I, as owner, or reported agent of g-wner agree to the conditions. SIGRAZ M TITLE DAM e Mite (PAID); YeUco (bn RI); Pick (Aqaba mw PC -RP 97 VID • • • a • • la ly `ta• wa. OWNER'S NAME SITE IDMTIOr MAILING ADDRESS 7M$ PERSON INTERVIEWED PaD Complaint # l %q Name & Relationship (i.e, owner tenant, etc.) DATE /i�S —//4 TYPE FACILITY REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as Different location may require submittal of proposal from registered architect. 9/1 n n iv A . nl 1A A% original sewage disposal system. licensed professional engineer or n Proposal approved Proposal Disapproved Inspector's Signature & Title 1]a Promsal aunroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE �/LJn,� DATE �ld-s—hg EPEES: Vbite (P D); YeUc w 03m EU; Pink CkpUamt) PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRCEMENTAL HEALTH SUMCES PROPOSAL FOR SERAGE DISPOSAL SYSTEM REPAIR Ac- SITE LOCATIOA PERSON INTERVIEW PCHD Complaint Dame & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER Cj PHONE REGISTRATION # Pro (include sketch locating all adjacent wells): RATE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional enginear or registered architect. Proposal approved Inspector's Signature & Proposal Disapproved S �a Proposal approved with the following conditions: to Procurement of any Town permit, if applicable. 20 Submission of as built repair sketch in duplicate showing: a• Owner Is name. b. Site Street Name, Town and Tax leap number. c• location of installed components tied to two fixed points (eage,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diamo x 61 dsap drywalls surrounded by one foot + gravel). e. Installer °s name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE i . I R Mitre (PCID); Yedlm M` m KD; Pink (Appliamt) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - APPLICATION TO CONSTRUCT A WATER WELL = please print or type PCHD Permit # Well Location: Street Address: To illage Tax Grid # ({ Map _3q Block -5 Lot(s) Well Owner: Name: "AdcUss: Ike 1- "O t i �- o J �1 � a-- :Sc� Yl. l2o 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 1' m # People Served Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason ® 5 S h Q. -Q- PoweaA for Drilling Well Type JA Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes No y Name of subdivision Lot No. Water Well Contractor: 4eio -El)oy d Address: , %G 14e- CQ4M_� I Is Public Water Supply available to site? .................................. ............................... Yes 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/plan. Date:- T.- r' 6 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 Department. During all well drilling operations, the applicant and/or well driller shall 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 Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate ell driller certified by Putnam County. )ate of Issue l 0 It Permit Issuin cial: ate of Expiration b" Title: \nit is Non- Transfe rable opy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 /9 #.T3, .r2ROU ROD 4 9^a S. 72 *-WA9 "W C'OSS Cut , i2 b5.89 /YS.S9 f 1 •3,gLoc*s Q4 ce arx. Nn SS(,,Ss 0 1o10910ec.E4 OZONE R -�O r ZONE iE Q� �( aor 9 TAX'W&P 73., BLOC. r 5-) COT V o. 9 -V s 19c, � °� A.eEA =0. 4,Ld tVY XRoN RoD �7 /fM9'r _ os � o I • •• K� �;mncj' 3Y e c�p�tG fjp/11 s YunKide R ge �(l D3 DN�LL . O 55 ( 72. 36" ,.- y 7i" r 0 �► OS 30 ° FhVCn7P/1f� iE. O _N55 � �j,9acadarn LL pole IinG a5 Shown on ii?ac rT14p QrOP�rtl� Pos7 +ton ; . APP ,nya �3 /9 #.T3, .r2ROU ROD 4 f� V� 1 •3,gLoc*s Q4 Q arx. Nn SS(,,Ss 0 p200 \ � ✓oloabi QO f•�q °� ' I ��= 3D� tVY XRoN RoD �7 /fM9'r _ os K� i 1 � Posi +Ion of 1 e'° Appro�' ;' P1,jTNA/Yl COON %�/DEPI�RPA9�/Vi°'uFiS//E�LTN Cq /one %N. fl /OS2 Su6diyision of �51iS�oorce/ does no /fn // ,; aader �h6J��!sdc�.ni�of�he.ov/no�rJ •. Co�inf/r/Reo /�jNStt/bde�rsion Cocr�e. f�jo�or7aro/ a {t%/is sub all ✓i,Sio1 is /)ofrepu reo!�°rro� to issuance of o hA"lo!i79 permif o consiraic- fron perm. fog �`15e subs v�foce seava!pe ar's�oos�a /Sys i»s rnus�ZOobi`t7i%�ed{�m the,.oa/riam Corrniy De�ar�mBn� • ' S�yned !/ I- GCi�AZi/ ; .? t!j",:,,e r..� O ®� � ��1 nVi�nme�® o/S�h s ewices Putnoin Coun� Dieio� OJcHeO/{% _ f/�.Stn� /ey Th�sor� �or�d S.0 /veyor /Ylo.vn � �fisoo, /✓!� /off' -�-9 . 067.Z ry yq :J- a'V1 k -7;9x / 7.3 .�LoCas Nofes' • ,possess %o� on /y cohere �i%�ocofcd. i Z� premises Shown' h�reor/ 6ei�� o,00r�io/� o��oi- o�o�r-� 6e %��i/�9 �b .5�e!oiy Bard�cfs� ��aw� os 6vrd�cfr fc�r�ns_ i 3j .oi-e/nlsas shod,, her�o/� behy .Cod 8 and Lod 9 os shown on Toeun� of /�tterso� Tb� �eafo No: 73 ,B /oeff S , dated June 2�, /96�. 9j ��einiSes Shown. he/eon /oco e'd ;7 7$1W --00 Cone AOMI' /y -i2 the Town of .aa�rte� son. Secs Locc,��on Maw, �d Sr4�i� /ey ,7ohnscn rs'ie stirveyo/ cviio inoc{& `his. mo/o� do hereby CBr{i y �ho,� fh� .Sarvgsy yjoon Gohl;:h IS 46'OS4e42O' was co�srswa /8 ! /W z cfi 9 AO, 11 .4 Phis /77d/a, e J4'S co/n/o /,e moo!• /�'lQrch. 27� /9g67 /WitP rev csed All .6, 1s0s S � f 1 S i <oT /2. i /Yo {es I AO an A✓erc 7, The f' ;010 dB TOh//7 O odan' . of QroPe ITnG a5 shown on fiber -mop 73 on Lolls A ,ZONE .e -440 (TRX A7/9� 7.3 :'- i 3 , 1, • j . es' t awl <ocafed on Tax 1Y1a`J 73 /OOSSESSiO/7 Orly GLl�lilc° /%70iCOfc°C� C8 10c%s 4'.4 o i /2./ A10-171Y Qy o /ch O�ne�� ,premises Shown hcreo.� 6ei�g o,00r><ior� o {,oi- o/oer-� 6e %n9in9 740 Al&, iy 6vrd cfs� �Y�awr> os Birrc.✓.c/! Fnr�ns. /Yo /es Cor>�ii/u�a! . O/-crnises shotuI? 6 and Lo-/ 9 Al 1717e become os shown on Town ojC /A4tterson Tat Taro ,Vo. 73 y ,B /vc/l S dated Jane 2Z, /96�. ? �>Aye o9 rC,JAdffi - 3000 *, 7) T%e %inq of this �S'cibdivision sho / /constitute the owr�e� -.s offer G/-c/n�;s�s .shown. hBiZ°o/i /oco�eo� �i� r5`ie,e -�O to dBdic6te thatoortion ofProioerty des9nat�a' for use by the COne 1<arni% ir! the 7bW17 of Toii✓r� of �ttBi-.sws ns a,oub /ice h9hwaf/ F�afiferson. See Locc�� ion iYjv�• Srbr� /ey .?ohnson yhe sLwcyon c�ho .rnoore Phis_ mQ/crY hereby ec�.fy rho hhe sai-vey c/Por7 which >'h /s rno/o ' boseool was corn�o /et�i� Morch 9 , /985 0/��✓ { cad this /7.70 4o4ps col-n I /er4e-o! /YJQrch 27�/9BS /eGU yo,o,o,il:sr�a acer�,seq'LQnrYQyor IV40. 3880 czP revi,�ed Moy 6, /-985 j i j. i• c