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BOX 18
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SITE
MAIL
DATE
PCHD canpiaint #
Dame & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY /OP,6
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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.
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Proposal approved. Proposal Disapproved
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!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)
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DATE / v S -�
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SITE LOCATION
MAILING ADDRESS
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PHONE
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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.
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osal�pproved Proposal Disapproved
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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
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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
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