Loading...
HomeMy WebLinkAbout2823DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.06 -1 -21 BOX 24 02823 I - yti Id ■, ■ {�� ■ 7 T o ik L Lr L' i r� I f I OIL lill INN 02823 P.. PUTNAM COUNTY HEALTH DEPARTMENT C� b DIVISION OF ENVIRONMENTAL HEALTH SERVICES E A10 o= ❑ ❑ 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 ��'c _J2 - - - - - - - - - - - - Z Serial Number YW, MMtlt, D0y PD5t Offire U.S Dollars s rid Csrft 18117882720 2010-09-23 105790 $150.00 J Clark Pay to v on f/ Address " Ad4rM X A Wd Memo e: roa SWU Poft 41MM-Al ft IF T. AND POSSESSIONS 1:00000800 21: W3 L L 78a 2 7 20.116 .. .. ...... 6-d 99MZ5gtl86 Hsmj SOV60 N CZ deS �b j e J;,4 Yl' V�, -oolo� tw� "00, DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER,.CARMEL, N.Y. 10512 (914) 225 -0310 ,,...._. -. �,-.,. t.,. �:• v-. �eaL"' r*` �.;:► s., ��� ._'iLe :•�O�"'+t�`t'i�L��"'....� _�..L+°'. .-zLj ....�.-,e...,.- .....o....,.. ,..�.y.rr..�,..._.� - L i..s-as vii' �: e-a 'r`ytal L• 1� ''SFi� L' r q 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