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01635
OWNE
SITE
MAIL
PERSON Il VIE PalD Complaint #
Name ,& Relationship (i.e, owner,tenant,,etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PROM
REGISTRATION #
(include sketch locating all adjacent wells):
NOM .-:.'° 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. �► �,
fig
Proposal approved Proposal Disapproved
Inspector's Signature & Title
the follawinQ 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 carponents 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 cwner,s. :�or reported agent of owner agree to the above conditions.
SIGNATURE TITLE
L: V&te (MD); Yellow (fin BI);1 Pink (tpli ant)
PC -RP 97
9 DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO C UNTY CENTER - CARMEL, N.Y. 10512 (914.) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
A ii A a<- PCHD PERMIT �A/�5 /:cyl�p
WELL LOCATION
Street Address
/� b
Toiwn Village City Tax
ep�I %% S .3.7 2� DD %(
Grid Number
�� -�.a1 ®D°�
WELL OWNER
Name
�'� SP
_
Mailing Address
A/VZQ=OPublic
Private
USE OF WELL.
1 - primary
2 - secondary
MRESIDENTIAL
® BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
OINSTITUTIONAL O STAND -BY
® ABANDONED
❑ OTHER (specify
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED �' /EST. OF DAILY USAGE-,Tbagal,
REASON FOR
.DRILLING
131NEW.SUPPLY []PROVIDE ADDITIONAL SUPPLY
PLACE EXISTING -SUPPLY 0 DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
LL °-
Z,/V:S UeFlc T `.l T�2
WELL TYPE
®DRILLED
®DRIVEN
®DUG ®GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
- ! Address:
WATER WELL CONTRACTOR: Name,Bo1!O 4Ar&iAAI �i/EL.L- Lo, ..z'a
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: _YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION-SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION ON S HEET
(date) (signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of 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 s.hall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County
Health Depart ent.
Date of Issue: Grp 19
Date of Expiration: 19 Permit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
PUTNAM.,COUNTY HEALTH.DEPAR7MENr.
liiVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simnons, M.D.
Deputy Camnissioner of Health - FIELD ACTIVITY REPORT -
Sheet of
INSPECTION
NAME �� / ��} -� Orig. Routine
Or' 1
ADDRESS
IM No.
MAILING ADDRESS
P.O. Box Post Office Zip Code
ig. Canp ain
Orig. Request
Canpliance
Canplaint Canp
Final
Group Illness
Construction
Reinspection
PERSON IN CHARGE //� Field, Sampling Only
OR INTERVIEWED Field Conference
Name and Title
Other
DATE TYPE FACILITY
TIME ARRIVED TIME LEFT
FINDINGS:
Ti
0
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
Explain