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HomeMy WebLinkAbout2504DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51.14 -1 -18 BOX 22 02504 N7 } �' ,, �1T �.. �, 02504 ORM I S NAME Ma L SITE LOCATION DATE a' r. .a PUTNAM COUN'T'Y HEALTH DEPART DIVISION OF ENVIRONMENTAL HEALTH SERVICES O �.K,�ae'*: �.•. o-..,.,_ �. z. �:, rW-. o-.--...:._. x..:: n.::. e. rr-,,.... �. .,e- .F..._•nmr+'s.•..x- .•.:.:a. ,a�...,w .,r•.: .. -..:. V - `��_� , . ....c mac. .ter-- ......._n..c..._- n,.�..... PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR PHONE W9f - 526 -3b/-3-5— 7H# 0-47 - 0 &- DD/-17 /Y Pam) Canplaint # e & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY -- R Gyfli {(;per F 4 PH= 7 3 q" -2-R2— 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. Proposal approved ✓ Proposal Disapproved Z o Datd 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 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, re rted gem of er agree to the above conditions. SIGNATURE TITLE DATE M7 0 LPg5: %bite (PAD); Yellow Mpn HE); Pink (kiiimnt) +l f +c F' s R I �k 5, 1, ti wdul, � :i .K a4. �ci•da�c, °li�o�� "r�•��sd� "r.i o © o a &.cjo Lv Oxv rl •f 4 0 A1414 c^4 y� • I W r L, LCj O\A/ ! i i i` 4 �O 0 w5-�L- e7 AAk� ©vvN l%(L FOR Svc(. e,-, t/7Y. 75-99 rk H l < DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # 6) 1�- ?p WELL LOCATION Street Address Town Village City Tax Grid Number 2.5 L ne- p I c k.► Qd OSi - 014 -6XI - 018 -000 -avdD WELL OWNER Name. Mailing Address Q(Private. fykyuma P ineI ZS �;�e- H o I I o w 2�1 Po+. VeJ!e+ OPublic USE OF WELL 1 - primary 2- secondary PJ RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O BUSINESS ❑.FARM O TEST /OBSERVATION O OTHER (specify 0 INDUSTRIAL b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT J2�0_ gpm /# PEOPLE SERVED �_ /EST. OF DAILY USAGE J60 gal O REPLACE EXISTING SUPPLY TEST /OBSERVATION 12. ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING j WELL TYPE ®DRILLED DRIVEN []DUG GRAVEL. C] OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name t�x4Ad AtZ��l (Z41 CI 0I Address: (1- �� lCartIV I IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY .- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (date (s gn ak6 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 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 otherwise n.taminate surface or groundwater. y Date of Issue: ���'''� -�� 19 z 0 Date of Expiration 1 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller