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HomeMy WebLinkAbout2477DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -42 BOX 21 I ' J ■ 7 i 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 1 � � .mac•►, dpi eicida Zia y pi t�,)& 60 c tA t� pw CPAAAudim C.D. e"Pu WOROM m IPA&mm Va&W 91. V ?0579 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 'V1pd 51H��3� . 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