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Home My WebLink About2521DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51.15 -1 -11 BOX 22 ... I .I No ' .■ N6 1.' ' LL ` 02521 SITE LOCATION 4A OWNER'S NAME & MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAI PERSON INTERVIEWED �j OFFICIAL USE ONLY K 01 33 -6 d � " t TM# Sj I , 0 r J' �APHONE 6Q PCHD Complaint # DATE TYPE FACILITY PROPOSED INSTALLER J—A A /e OR fJ,�� PHONE 5-2.6 727e ADDRESS / �/' /�/6 -r�i?��4 R� 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. L" L &.7�/if I-S"F C f49L JQ /A/,5'7-,l Z L E1 / n/ , /-d T p/✓ A i--, ,O A Alr° 1,i4 I yr Oiff , rV-9 _ - -I; as owner; -or r �rted-~gent of -wNmer agree to die conditions eatte%A zn this f orm, _ SIGNATURE TITLE .0 W r J DATE D� 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 corners). 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 approved Inspector's Signature &Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DA r a p o s a 1 Page No. of Pages In H -G 11NE40 'NO LANDSCAPING RESTORATION, OTHER THAN GRADING DISTURBED AREAS, IS INCLUDED UNLESS SECIFICALLY STATED.` VP PrQPdSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Payment to be made as follows: dollars ($ A FINANCE CHARGE OF V/2% PER MONTH WILL BE ADDED TO ALL UNPAID All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING Authorized Signature _ Note: This proposal may be withdrawn by us if not accepted within Acceptance of Proposal— The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature days. LEONA.R ®1 & SON CONSTRUCTION, INC. .....S.GAR(JLYN._LIRIVE.q CORTLA.NPT.MAfgUFl, NY.1��S?:. (914) 736 -9010 ° ( (� LIC. # WC- 3112 -H90 a LIC. # PC-560 r Ie y SUBMITTED TO __� _ —� PHONE DATE STREET ` JOB NAME CIT , S and ZIP CODE 0� " JOB LOCATION ARCHITECT fDATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: 11 1 zt;T-S 11-7 3 23 Aj _. +--- fEl�azsurc,•� 1z 16 -� z2 Gc15'fi lt5 > .tz'rolrl �ro� "Q. 2 1 rQJC�t 1Lrwy I 5-o 7� ... - _i..�... -� H -G 11NE40 'NO LANDSCAPING RESTORATION, OTHER THAN GRADING DISTURBED AREAS, IS INCLUDED UNLESS SECIFICALLY STATED.` VP PrQPdSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Payment to be made as follows: dollars ($ A FINANCE CHARGE OF V/2% PER MONTH WILL BE ADDED TO ALL UNPAID All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING Authorized Signature _ Note: This proposal may be withdrawn by us if not accepted within Acceptance of Proposal— The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature days. DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 �►PPL3^C, aN. T.Ou CO�tTS.T,R JCT-•- X-- WkTER; -WELT; ... ......,... ` ' _ PCHD PERMIT # WELL LOCATION Street Address St ' T wn Village City Tax Grid Number I�L2:I �d�� 7? '.sr/--0/S— WELL OWNER Name " Mailin Address Z %Gl 19 0�7r pPrivate Pd ��/�oZ,3 OPubiic USE OF WELL 1 - primary 2- secondary �BUSINESS RESIDENTIAL 0 INDUSTRIAL ❑ PUBLIC SUPPLY O FARM O INSTITUTIONAL O AIR /COND /HEAT PUMP O ABANDONED O TEST /OBSERVATION O OTHER (specify O STAND -BY 0 AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED ,5- /EST. OF DAILY USAGE ,� Sal REASON FOR DRILLING O REPLACE EXISTING SUPPLY 13 TEST /OBSERVATION CI ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING) 13 DEE EN EXISTING WELL DETAILED REASON FOR DRILLING CO&I Gx► -h ",1C We./ WELL TYPE DRILLED ODRIVEN 13DUG [3GRAVEL 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: Name ( !7/ t lC�'1 ' �� t i), �_ Address: 0 1t Z G-errZ% 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 SKETC&A SOURCES OF CONTAMINATION PROVIDED 2i �J ON SEPARATE SHEET (dat ) jj ( gnatur ) 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 suc a manner as not to degrade or otherwise contam ce or groundwater. Date of Issue: S 19 Date of Expiration 0 19 <f5�G/ --,Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller BRUCE R. FOLEY, R.S. Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERN•IIT Dear DATE RE: Department of Health ReNiew of Proposed Sewage Disposal System andi or Well NAME: pou-, .ADDRESS: /�� A). SdLO r-e— TOWN: I'[.l:{7'y m U �/ 0 S? TA. �IAP: 015— 000/, 01/ Please be adxised that an application for a Construction Permit relative to the construction of a sewage system and'or well proposed for the above captioned property has been made to the Putnam County Department of) Iealth.; attached please find a copy of the latest site .plan; If you have any questions, concerns or information which may bear on the Health Department's re'iew of this application, you may call NIr. Morris of the Health Department at 278 -6130. Very truly yours, B. TITLE: RECEIVED BY: ADDRESS: (?0 TAX MAP: BRF/ jp syswell i, DEPARTMENT OF HEALTH t Division Of Environmental Health Services } 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 FORNIAT NEIGHBOR NOTIFICATION CONSTRUCTION PERN11T DATE : 1 p F. x RE: Department of Health Review of Proposed Sewage Disposal System andor Well �l�s Vj f ,ADDRESS a: TOWN: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and.'or well proposed for the above captioned property has been made to the Health. —, rae'had please- fmO, a cop of - the -1 test -cite- plan_._ '.... a If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call %Ir. Morris of the Health Department at 278 -6130. Very truly yours, Im TITLE: RECEIVED BY: ADDRESS: "k- fk"-' TAX NIA.P: -5-1. to BRF /jp sy:sWell A. DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 FORNIAT . NEIGHBOR NOTIFICATION ' CONSTRUCTION PER2\11T. DATE Dear RE: Department of Health Review Proposed Sewage Disposal Sys NT ME: 6DLtj loo NQ ADDRESS- Si �%J S T0WNT: �,,�q M V TAX MAP: -r) 1 Please be adNised that an application for a Construction Permit relative to the construction of a sewaoe system and'or well proposed for the above captioned property has been made to the CooWN . epartment.of Health. Attached Tease finda4cop�.of the latest site flan. _ ..`� .. . ... R..- �...�.�. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call NIr. Morris of the Health Department at 278 -6130. Very truly yours, TITLE: RECEIVED BY: X-.,- ADDRESS: v/�. A',' TAX 1%1e: BRF!jp syswell BRUCE R. FOLEY, R.S. .j Acting Public Health Director �i 3 �r t .2 4 of ?' t tern and, or WeU i Please be adNised that an application for a Construction Permit relative to the construction of a sewaoe system and'or well proposed for the above captioned property has been made to the CooWN . epartment.of Health. Attached Tease finda4cop�.of the latest site flan. _ ..`� .. . ... R..- �...�.�. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call NIr. Morris of the Health Department at 278 -6130. Very truly yours, TITLE: RECEIVED BY: X-.,- ADDRESS: v/�. A',' TAX 1%1e: BRF!jp syswell PUTNAM COUNTY DEPARTMENT OF HEALTH o ,.b DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well T,®cateon °tree Aadess: Al Ore_ ° : ",- &L 'T ownlVillage: &% Tax rid" . Map .5'/ Block O/, j Lot(s) �® Well Owner: Name: Address: er Z Old #Ij PJ ice¢ V Y r 1402 3 Use of Well: 1- primary 2- secondary ">e sidential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length #ft. Length below grade __q�ft. Diameter _ in. Weight per footlb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded A Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: V1 Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours &7 Yield ,69_ gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or. sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface . If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Mj, ors Capacity %Z. AL. IOU Depth l De p Model (1b_ Voltage 22-0 HP .Y2- Tank Type ��,j,[ Volume. Date Well Completed loll Putnam County Certification No. 003 Date of Report f o l d Well Driller 'gnature) Num Exact location of wenwitn atstances tout least two permanent tanamarxs to De proviaep�on a separate snetupian. Well Driller's Name &Q r-Aesicmn W P� Address: Itt Z Signature: Date: 011(&/91 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 (316) 466 -2660 (718) 793 -7400 t' (212) 385 -0600 DOUGLAS H. KRIEGER - -AT LAVN 98 CUTTER MILL ROAD, GREAT NECK, N. Y. 11021 June 25, 1999 Putnam County Department.of Health Division of Environmental Services 1 Geneva Road Brewster, NY 10509 Att: Mr. William Hedges. Re: Filing Well Completion Report premises 151 North Shore Road Lake Oscawana,Putnam Valley,NY Dear Folks, Enclosed herewith is the well completion report prepared and executed by Boyd Artesian Well Co, covering the new well on my property. Please file the report. Would you be kind enough to date, initial and return the enclosed photocopy of this letter so that I know.the report was received and filed. Thanking you for your courtesy, ,. Very tru-- ly- :-::v6ii =.ra� .. _ _.. .. . �1 DOUGLAS H. KRIEGER DHK:sl encs. (3) Received and filed original Well Completion Report 1999 LO, W/Y'y All fit moo UP 6-Mb 2&V / J, 4 } n 1, 2,052 986 Op9 986 OOg US Postal Service Receipt 'f®r C �ified Maii-: us Postal seniice' Rei $ ®� �eAiedeai No Insurance- Coverage Provided. � � No Insurance Coverage Rrcvided. Do nofuse for lntemational Mail See-Mverse .- . . ntto: Do not use for International (Nail` See reverse I Sent to Strut Ourqbw (q Cwt I., &re Numtiei