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02477
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSA Y3TElVI REPAIR~ „..'.<
OFFICIAL USE ONLY
a $o -ad
SITE LOCATION 4 0 &SC,.4v,-1,A ti-,4 /LIES /�d A U, TM# _51 ft /
OWNER'S NAME oajur l z,4be,n wwe_ l &_ PHONE
MAILING ADDRES
PERSON INTERVIEWED- Q6,, aC. d PCHD Complaint #
Name & Relanonship (i.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER a.f cojj,ds Co, PHONE ! 11-S a 6 - e9 y V6
ADDRESScP3.3 r? u. fuj�,-79 REGISTRATION#
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 from licensed professional engineer or registered architect.
.._ as owneLor repgrIgL gent of owner.agree-to.the..conditiQtl stated_.on,this
SIGNATURE TITLE 120+t►,MaCi "oe” DATE4�Q�1
Proposal 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approve
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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8 DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
- aP.PLICATLON; TO, CONSTRUCT : -A :wATF.R;. WEB
PCHD PERMIT
WELL LOCATION
Street Address
To Village Ci y Tax Grid Number
WELL OWNER
Name
" ,i./
Address.
Q .0
rivate
O Public
USE OF WELL
1 - primary
2 - secondary
❑.RESIDENTIAL
0 BUSINESS
13 INDUSTRIAL
❑PUBLIC SUPPLY QAIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
OABANDONED
❑ OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
EW SUPPLY
OREPLACE EXISTING SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY
❑DEEPEN .EXIS ING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
_PL•
-
WELL TYPE
DRILLED
DRIVEN
ODUG GRAVEL
El 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 ftl fttoi M 1!> M1 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
. DISTANCE TO- RROPERTY - •RROM- NEAREST- :GrATER - M_AIN:. :'
104- se y . ez_ _:. :..:..._. _ ..�.._ . .:._._
LOCAION SKETCH & SOURCES OF CONTAMINATION PROVIDED
16 Q ON REAR OF THIS APPLICATION � EP T 96z_"o
r
(d1at e) (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
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provi by
Health De art ent.
Date of Issue: /4 19_
Date of Expiration: 19 Vermit Issui
Permit is Non - Transferrable
M.
of the Putnam
the Putnam.County
ng 'ttttr ci a
IFUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVff CES
APPL1iCATffON TO CONSTRUCT A WAT ER WELL
please print or type PCHD Permit #
Wen Location:
Street Address: Town/Village Tax Grid # 1'
60 05CAWAVa 14PS. d:1, ii ,qrv- -kA-J.L0 Map Block Lot(s) �--
Wen Owner:
Name: S M I T✓i r.cy&1.V
Address: / / 1 f 4.4/, �12,
c7.r?-9!,z TaatrP- r-4 --T
-f.li-Nraqy V 1
Use of Wen:
v- Residential Public Supply Air /Cond/Heat Pump Irrigation
I -P rimalry
Business Farm Test/Monitoring Other (specify)
2-secondary
Industrial Institutional Standby
Amount of Use
Yield Sought - 6 gpm # People Served _2_ Est. of Daily Usage 20 gal.
Reason for
X_ Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
d kVJzLt.
Al o &,&b W r*Lr
for BD>rilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No A(
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor: '�o ,� ,� Address: /7A9, V A-L I e fl
Is Public Water Supply available to site? .................................. ............................... Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on se ate sheet/plan.
....Applica_nA Signature:
PERMIT TO CONSTRUCT �kTER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROV EIID_ IFOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified b Putnam
County.
Date of Issue AIIJ00 Permit Issui g Official:
Date of Expiration _ to ® Z,. Title:
Pe>rmi>t is Non- T>ransffenra Ile
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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