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02401
PUTNAM COUN'T'Y HEALTH DEPARTmu
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
6, �
OWNER'S NAME lrna. 90,1e4'Aine fleLmena PHONE
SITE LOCATION 1025 % eekakill t( 1l ow Road - Putnam Va l e& . NN TO
MAILING ADDRESS 1025 `leek ikil. No.Uow Road - Putnam Vall eu . N
225 -938%
PERSON INTERVIEWED lleLmena (owner) PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 515197 TYPE FACILITY RnLvate Dwa, Ln
PROPOSED INSTALLER Aahopac Sanitation Septic, Inc. PHONE 628 -4526
REGISTRATION # 4/ 217 kennicut fl al Rd., An Aopac, N.Y. 10541
,(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.
Rej�ace atea aeptic tank witA.Naatic aerjtfic tank.
(Tank runchaaed 6, owneni
Ue' ck 4ie. da and ii! . ace dnaindc e K{ielda with nechan_c ens it neceaaan, .
Proposal approved Proposal Disapproved
Inspector's Signature'& Title
a �
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 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,
SIGNATURE
(PW: White
agent
owner agree to the conditions.
TITLE / DATE 611 lq7
OW AfA 2
Yellrcw Umn BI); Pink (Appli®nt)
MAHOPAMY
SANITATION SEPTIC, INC.
Septic Tank Service
Kennicut Hill Road
MAHOPAC, NEW YORK 10541
628-4526 Joseph A. Mantovl
x 1/1-1, 199,
114* Anv IQ21 /6611
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DEPARTMENT OF'HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
1d:r7 7 PCHD
PERMIT # -i6
G
WELL LOCATION
Street Address
1a ty Tax Grid Number
WELL OWNER
�vt,
ing Addre �l
ail/0 -J, � ('� ✓zz-sv
.t8'Private
O Public
USE OF WELL
1 - primary
2- secondary
;CRE$IDENTIAL
0 BUS! INESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
b INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT 6 gpm/ # PEOPLE SERVED ---- /EST. OF DAILY USAGE �I y� dal
13 REPLACE EXISTING SUPPLY 13 TEST /OBSERVATION Q ADDITIONAL SUPPLY
E14EW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
'DRILLING
WELL TYPE
/ DRILLED
ODRIVEN
DDUG
C]
GRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES �NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Namev Address:�S Y�/�����✓�ii
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY PROM NEAREST WATER MAIN:
i
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
❑ON SEPARATE SHEET
(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 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.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or oth w se contaminate surface or groundwater.
Date of Issue: 19 v! Z
Date of Expiration 19 Pe it Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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