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HomeMy WebLinkAbout2499DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51.14 -1 -9 BOX 22 Ir -r .. him . IN VL 02499 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use ❑ rRepair pair Permit issued in last 5 years ❑ pair within Boyd's Comers, W. Branch or Croton Falls Res. 11 within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION TOWN RAMin OWNER'S NAME MAILING ADDRESS /''rae,r APPLICANT K6 a(UakS D(11i5o10.gwjnb+ ,-XP••�'�' �� +Name & Relationship (iA., owner, tenant, contractor) DATE FACILITY TYPE ReS e! PROPOSED INSTALLER /� _ n�i ADDRESS 90Y A6 At r�..�ca_ Pd �J���1 REGISI JIT-1 PERMIIT #mod -"' of in Watershed Ld Delegated ❑ Jointl Review o� TM# �1 ►f / PHONE # 5716 - s 6677 A-111Aos, VA 1VV IN aS7� Z 1 PCHD COMPLAINT # t� C7�PH0NE # TION /LICENSE # I /U rJ 0 77 Ira X Pro osal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree to the itio t don this form SIGNATURE LE DATE (owner) I, the septic instal r, a ee omp theA ns o permit the septic system repair / SIGNATUR I E C DATE ` (installer) Proposal approved with the followi g conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Er Proposal Denied ❑ Inspector's Signature & Title Date Expiration D to Re air proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 V 0 e y''" ✓� c8�� W.A OR "J fl rates N-eep ro 7se (e;r.o uc D //1% 70 /4me764 (-vDo- (WeTPL rA N K 1 t U AM COG WO DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL WELL LOCATION Street Address �J ,J ,/ Town/Village/City Tax Grid Number WELL OWNER Name �r7 Mailin Address 6 , ®E�a s�« pa- Rorgeor 2-cs4 �- Nvr-p+ 4avE,4 frar Owi4a:s NeW i4ve ek JV-X 119'/o Private -b-Public USE OF WELL 1 - primary 2 - secondary 19 RESIDENTIAL 13 BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP D FARM Q TEST /OBSERVATION .C] INSTITUTIONAL. O STAND -BY O ABANDONED ❑ OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING 0NEW SUPPLY O REPLACE EXISTING SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION. JXDEEPEN EXISTING WELL DETAILED REASON FOR DRILLING Cvfz R F."&r a L' WELL TYPE DRILLED a DRIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? < YES "IF"WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: nl 0 RT N 1 -�v6.+ P� PSitT 1 (%aN�arr Lot No. Rr' er —Ay WATER WELL CONTRACTOR: Name �G,�,r,, l4r�p sue,+ IN Address:l2_0 ?�6�.5s 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 []ON REAR OF THIS APPLICATION ®ON /MF, Z y (date) , (signat re 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 y (30) days of the completion's <of water well construction, the applicant s.hall: 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 r,j by h n �, —�Q,.. Health Department. ©� �� ..,..,..Date .of.. _Issue:..--- 1q��� - - Date of Expiration: 6r-/ _19 ermit Issuing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: owner Orange copy: Well Driller MARVIN O'DELL Inspector TOWN OF PUTNAM VALLEY BUILDING, ZONING, AND SANITARY DEPARTMENT July 14,.1987 TOWN HALL PUTNAM VALLEY, N.Y. (914) 626 2377 Mr. Robert Morris County Environmental Health Department Carmel, New York 10512 . RE: WATER WELL TM #26 -4 -7. Daar -Sgt The proposed redrilling of an existing water well as shown on.the survey of W. Irish dated December.30, 1958, has been reviewed and approved by.this office. Yours. truly, Marvin 0'D Building and Zoning Inspector PETER C. ALEYANOERSON County Executive ® O K 34-6c DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914.) 225 -0310 July 8, 1987 Mr. Robert Rich c/o North Haven Property Owners 69 Devonshire Drive New Hyde Park, New York 11040 Dear Mr. Rich.: -: _....._..._. _.._..._._...__ _ . P..: Proposed well JCtIN SIMMONS. MO Oepu[y Commissioner JC�N KARELL. Jr, PE. Director Please find enclosed_ your application to construct a water well. This application must be submitted to Putnam Valley's Building Inspector, Marvin Odell, prior to the review by this Department. Only after Mr. Odell's written comments are received by this office can the approval process continue. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Ver my yours, Robert Morris Environmental Health Technician RM:pt Enc. cc:RM File` JK 1, A'111 r 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 Address J Town/Village/City Tax Grid Number Rt4f_ Izo VA"- _57'Ecr Z6 q WELL OWNER Name Mai lin� Address (y 79. e-;Ej -r nn .cN /c. fvJcM WA e., (to ?Eat 0ivrck%y N ,r I4vo< I✓ X If,�/a 3kPrivate OPublic USE OF WELL 1 - primary 2 - secondary .19 RESIDENTIAL O BUSINESS ❑ INDUSTRIAL ❑ PUBLIC SUPPLY (:] AIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION U INSTITUTIONAL. ❑ STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING ❑NEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY ❑TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING v rz 2- c'b 15 ..yr��y WELL TYPE 13DRILLED EDDRIVEN ODUG GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES �_NO IF'WELL IS LOCATED -IN A REALTY SUBDIVISION, 'NAME OF SUBDIVISION ;­­­­- tJ c /irN Lot No. ar at wAy gisiw e F l 6y 3 WATER WELL CONTRACTOR: Name �ic,;b.vq�/ Ar�Oct:s:_j 1 ni Address:0_0. IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A 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 [DON (date) , (signat re 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 s.hall: 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 Expiration: 19 Permit Issuing fi icial Permit is Non - Transferrable Mite copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 Orange copy: Well Driller -4�i� C IC rlo-�• - � � o � 0 °u SIN I o n i 7� Y ��� RM . At Of Ot Do Al � al / I I� I ; I� I -a f ; y i'� eY 1 ; �?� 16 - i �� "'fin s <+�+�ys ���"?� k�.•�� 4d�i"�'�aE �� r x <a�a:' .s�;,�.K3t, -s;, ". .r...i. ?ice? :�,r�,�`r��sa�aa�t,��rr�`S:i� - {�'z�al. ,c ,:��2 �a,=:�•��''^•Ea... ,.�i.M.. 4",�"e°.r�+:'�. �:�� �'. •:fi. ��. =5 R fir: •,off '� ,,`6? ok�` \ �D 44 n NO xill W64e, •F, + \ \ \ \ • ��� 27 93 4 f�E moo. `o sx •#�,� P7; r a o ,e s17OA IAI s�.�,� ,� : i� a moo• JU�'YES�i+A •ft /.V '•'T ,47ssess /ol� D,+/,L y ! P.P.,,EP.el,PED D�EC.eMO✓g.0 .'bt.C•,'.o� fI i Ml L I (L IN IN k 1� ;4