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HomeMy WebLinkAbout2040DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.41 -1 -5 BOX 18 ro Ll jr 16 �IA61 6 r , k, GKO SITE MAIL DATE PCHD canpiaint # Dame & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY /OP,6 pc 7 9 y PxoNE 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 fran licensed professional engineer or registered architect. iJi) f�Lo QC, , &W <-A � 4-GL Pc Proposal approved. Proposal Disapproved s Sianature & T Da !roposal 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 canponents 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 report ag nt of owner agree to the above conditions. SIGNATURE J TITLE MIS: W-itie (PCHD); YeUcw (Tan HE); Pink Lk#icant) q DATE / v S -� N-611; SITE LOCATION MAILING ADDRESS v e- s IR PHONE TK# V c279'- K2 �-j 6 PERSON INTERVIEWED r VA 2Ae PCHD Ccmplaint # ) ,� Name & Relationship (i.e, a tenant, etc.) DATE TYPE FACILITY AC-4 n Z.- IV- ' / i 0. to / AC PROPOSED INSTALER PHONE 7 4! Proposal (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. kcm D U,6 OLD k6r w 75:: CV,4Lt o,X S C osal�pproved Proposal Disapproved K 7*z Inspector's bgrft&e & Title Date roposal 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 cxanponents 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 31 [FIRS: RAte ( ;Yellow (Zb HE); Pink (A pli,cent) ALL-PRO ROOTT E inc. Elmer Galloway Rd. Katonah, NY 10536 914-232-8888 0 - �jELL- -- N A-. 4 - iZ Z b 2 o WE�LS w' (0 1 00' rT t 74 DEPARTMENT OF.HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ....`...,,,_. "_APPLICATION TO CONSTRUCT A WATER WELL P CHD PERMIT #� WELL LOCATION Street Address Town/Village/City , Tax Grid Number WELL OWNER Name d Mailings Add ess -Private koe �/ 6,.e, 13-Public USE OF WELL 0 - primary 2 - secondary QUSIDENTIAL ® BUSINESS .O INDUSTRIAL PUBLIC SUPPLY OAIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY ❑ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PF,OPLE SERVED_ /EST. OF DAILY USAGE gal REASON FOR DRILLING ONEW SUPPLY PLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN E3 DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name galC6% e Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES te-' 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 ARATE SHEET (date) 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 shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the County Health Department attached to this 3. Submit a Well Completion Report on a form Health Department. Date of Issue: �,' 19 g% Date of Expi rat i 19 requirements of the Putnam permit. provided by the Putnam County Permit Issuing 0 ici Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: OHmer Orange copy: Well Driller i, .1 ; 'T U � i S t i I