HomeMy WebLinkAbout2375DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
41.14 -1 -68
BOX 20
02375
§.Jj
Liss
-s!
tzr.'j
;NJ
;
ry
: F
��
i;
.,
,.
,;
r
;�T
02375
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION_OF ENVIRONMENTAL HEALTH SERVICES
OWNER'S NAME %ors• Char. Qagen PHONE 964 -6721
SITE LOCATION 4 Brsovh4 ide toad, l utnam Va.Uec , Ny T1# �/.
MAILING ADDRESS 4 ars00%ide Road, Putnam VaUU, NY 10579
PERSON INTERVIEWED /ors. Qa2en (owners) PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 101271900 TYPE FACILITY & Lvat e d weU Lnn2
PROPOSED INSTALLER Mahopac Sanitation Septic, Inc. PHONE 628 -4526 .
REGISTRATION # 41 485 Kennicuf #ai Rd., Mahopac., NY
Proposal (include sketch locating all adjacent wells):
Nam: 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.
1"taU new aeptic tank (cement oa lLaatic) in lame Location.
Title
,;,r
K&PW�Dl9i�oi t.
�/%Ati,� LoC -+4�ys a1
Proposal Disapproved
Proposal approved with the following conditions:
\,F�
I D-Z 1 9 �
to
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 re agent of owner agree to the above conditions.
SIGNATURE TITLE OWhICt DATE
IP1E'S: Hhibe MV; YeUaw (Tovin RI); Pink Qfti i®nt)
DEPARTMENT OF HEALTH
Division of Environmental Health,Services
WO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street A dress
_// aiegl&i�&
&�e
/1
g it ion' Tax Grid Number
-'/ / s / /-- / - 4 e
WELL OWNER
ame mailing
Address
'Wrivate
O Public
USE OF WELL
1 - primary
2- secondary
® RES AdE NTIAL 6PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED
13 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY, O
AMOUNT OF USE
YIELD SOUGHT ,5J gpm/ #
PEOPLE SERVED /EST. OF DAILY USAGE �® gal
REASON FOR
DRILLING
19NEW SUPPLY
O REPLACE EXISTING
SUPPLY
O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
IRDRILLED
DDRIVEN
®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: N
Address V-6
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
r1OX REAR OF THIS APPLICATION []ON SEPARAT SHEET
( te) (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 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 attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County- -
Health Department.
Date of Issue: -�% 19�
Date of Expiration: 19 ermit ssuing fficia
White
Permit is Non - Transferrable copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner,,,;
Orange copy: Well Driller
00 ^ 90.00 "` s
ZI'f6
Op �
00 06
// \
/
\ \
00'06' 00'06 v �� � I ►`
Co
ul) co
cv
po N N
40. O B2/ 6g 2y CC)
2/ c� 203.32 I
90.00 59
_ ` v 00
e R 90. 90.00 —t.
_� OOKS IiDE
' 1
t; c\i
67.76 :r v- o � 45.34
bg sp/ 101.23
, � o —" — •
63.E f 00.
0OB /
CO
C\.i
co ti
484.00 I
"p!. N ° OOSB
PUDDING
A : ' STREET
i'
N
486.52
hco• c1,
hq5 dJ U
a N o ° W �.
N
JAB
424.56 m
192.09 ^ _�
cv N
i 172.22 438.55 i 1`ti 7
M
M
A/ r- 3 / 00
/ * 96.04
.. .er
n
BRUCE R. FOLIrY
Public Health Director
DEPARTN, =MT OF HEALTH
Division oaf Environmental Wealth Services
4 G.ceva Road
Bte�cS�:C, ties, Yot'.< 10509
TeL (91;) 278 - 6130 Ft: (9141) 278.7921
Date:
To: zf //
Putnam County Environmental Hearn
Fay
:No. Pages'._..
and din; cover sheet)
Notestivlessages
In the.event of transmissionfreception difficulties, please contact this office.
T 0-6-
,-
-j-
PUDDING
'STREET
53. io 90.00
90.00
m
tn
C%j LO
Lr) C%i
cli
co I
:z:N
203.32
90,00
BROOKS 16E
90.00 90,00
'STREET
v�
s I lo,3orF
McA-7u1ZEMsNT5
M �
-t-0 w Ka OF
y�ir o A
7r M 41. 14 - 1 - Coq
SCALE :
'
I"
ZO -C>
®m��
-
`z
y�od
C N b d
lWl�REMN
tl �
n
o d n c
�m
v-o y x
®
®�a�
b e
■emm
fi 4 °v v
®■�
4 3
■■■■■■■■■■■■■s■
v -W
a „ u
U1
v o, a V Z v
ti ti
O
�I
�I
i
s I lo,3orF
McA-7u1ZEMsNT5
AS-
-t-0 w Ka OF
PUl"Pub.n VAa1:LWY;
7r M 41. 14 - 1 - Coq
SCALE :
'
I"
ZO -C>
®m��
��Y
ww
/i
lWl�REMN
�m
®
®�a�
■emm
®■�
■■■■■■■■■■■■■s■
AS-
-t-0 w Ka OF
PUl"Pub.n VAa1:LWY;
7r M 41. 14 - 1 - Coq
SCALE :
'
I"
ZO -C>
pP.u� tn. LY�t-1 Ra.
P.O.TSo X- SIS
sNFaJOROGt�- , *1N. 10"&,l
or- .r- r-lv>;NCUr