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PUTNAM COUNTY HEALTH DEPARTMENT C�
b DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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SITE LOCATIONIQ3
OWNER'S NA
MAILING ADC
APPLICANT
Repair Permit issued in last 5 years XF Not in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. K Delegated
Repair within 200 ft. of a watercourse or DEC- 5ffp//ed wetland ❑ Joint Review aa
I%cice 0d', TOWN t,677 y, '%� �rM # �� . 6 " / ` P %
Name & Relationship (i.e., owner, tenant, contractor)
DATE ' t) Z? FACILITY TYPE PCHD COMPLAINT /#
PROPOSED INSTALLER S � C.,/;�':f i ��''F FIONE # Pdkr 1 ?h? �� •!
ADDRESS A by L. Ar REGISTRATION /LICENSE # J I k ?q
Proposal (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
nature and extent of the repair.
pAlPv five FY—I J T"i1,f1 TE7 41 S.4 c, , 15ph e
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, ree to comply M t conditions of
th t for the septic system repair
unE i a TITLE, OHTC lr0navT
(installer)
Proposal approved w-ob the following 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 baZ until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved
re & Title
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
i• -d 996 69Z99ti9 6
Proposal Denied ❑
5PAI-3 Z,� 0
Dpie
Yes
Expiration Date
No 0
Rev. 2107
HS(12i e6Z :06 OL ZZ deS
ii\juuiRy DATE : 09/23/2010
372800 PUTNAM VALLEY 62.6-1-21 ROLL SEC TAXABLE
PARCEL PRCLS 260 SEASONAL RES
BF,LLnZA THOMAS J TOTAL RES SITES 1 LAND $170,000
3 HEMLOCK POINT CT TOTAL COM SITES -0 TOTAL $376,200
SALES RES SITE R01 RESIDENCE
T
EXTWALL MAT WOOD STORIES 1.0
======= = = = = == SITE=== = _________ = = = = =1 GRADE ECONOMY - - -AREAS - - -
PROPERTY CLASS SEASONAL RES HEAT TYPE HOT AIR 1ST STORY: 773
ZONING R2 NO. OF FIREPLACES 1 2ND STORY:
SEWER PRIVATE NO. OF BATHROOMS 1.0 1'/2 STORY:
WATER PRIVATE NO. OF BEDROOMS 2 3/4 STORY:
UTILITIES ELECTRIC I ATT. GAR. CAPACITY FIN BASMT:
NEIGHBORHOOD 1 28010 I BAS. GAR. CAPACITY TOTAL SFLA: 773
===TOTAL IMPROVEMENT ITEMS 2 TOTAL LAND ITEMS 1 . ========
TYPE SIZE1 SIZE2 QUANI TYPE FRNT DPTH ACRES SQR FT
1 PORCH,OPEN 1 WATERFRONT 206 1.19
2 PORCH.OPEN
Fl=MORE ITEMS I F6=ASMNT INQUIRY F10=G0 TO MENU
75.20 03-050 F4=NEXT RES SITE ON FILE F9=G0 TO XREF Fll=PREV ITEMS
fee
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Serial Number YW, MMtlt, D0y PD5t Offire U.S Dollars s rid Csrft
18117882720 2010-09-23 105790 $150.00
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T. AND POSSESSIONS
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER,.CARMEL, N.Y. 10512 (914) 225 -0310
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PCHD PERMIT #104-2
WELL LOCATION
Street Address ����-.Town/Village/City
Tax Grid Number
Name iling Address
Private
WELL OWNER
�.
j
, O Public
USE OF WELL
RESIDENTIAL O PUBLIC SUPPLY
O AIR /COND /HEAT
PUMP O ABANDONED
1 - primary
0 BUSINESS O FARM
O TEST /OBSERVATION
O OTHER (specify
2- secondary
0 INDUSTRIAL b INSTITUTIONAL
O STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED_ /EST.
OF DAILY USAGE 45
REASON FOR
O REPLACE EXISTING
SUPPLY O TEST/ OBSERVATION
GI ADDITIONAL SUPPLY
DRILLING
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WE LL
DETAILED
REASON FOR
i
A
DRILLING
WELL TYPE
DRILLED
DRIVEN
[]DUG
[]GRAVEL �
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: M At
Lot No.
.WATER WELL CONTRACTOR: . Name
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
_ . DTST-A.dCE.:: TO- FROP'?:RTY -FP..OM NEAREST WATER MAIN: e Con
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
,�. RON SEPARATE SHEET
CID
'�.eTYha.1J
ate) (signat e)
�j3 -52> 4 to
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 manner as not to degrade or rwise contaminate surface or groundwater.
Date of Issue: " to 19
Date of Expiration "t 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