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01571
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SITE
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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
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