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HomeMy WebLinkAbout2837DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.10 -1 -19 BOX 24 I yL r+ I ,` r I, � ' r 'I .1 .� ` 6 ILL. 02837 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL S STILA '. OFFICIAL USE ONLY —0� SITE LOCATION) 01 W •'4 r,� -� 1 �'' TM# 6 � %D OWNER'S NAME ,j ,hA-ryiy e C 66 --d, ®w PHONE 13 9 j MAILING ADDRESS P 04 c ,-C- Ar 10u'7-,w-a1y7 0 PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER G'A w!y 1/s CO—S7– COj • PHONE hLJ J? d W4 ADDRESS X33 c.�, �v ,Sl ©!j/, E� ���i /? f.� REGISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be I 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. c! its ? cs owner, or �tiertzd Ago-l;± of Jwtlei' a;r e to c uditi3ns ski #ed on *his form: _ .. - - __ v .on ... _ .. _ SIGNATURE �J� �� TITLE DATE r%-I 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. Propos ap oved arl 0� Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NIL Y T A OVA 27 . . .................... 01 1 04 :1 ;, T-S4 5'ef3 AtOf,46e_ L104 Ll r'o 66 Aldec _vq) A -ro A.M Ll ,4 67) 13 'm ( �,/ / � 9 725 .13. 6s.v CANOPUS CONSTRUCTION CO 233 CANOPUS HOLLOW RD, PtV, Nu 1 / 10570 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO C TY CENTER - CARMEL, N.Y. 10512 (914).225 -3641 `APPLI CAT ION TO y CONSTI�i)CT 4J1TER �GJELI, ' x PCHD PERMIT #� , WELL LOCATION Street Address Town/Village/City Tax Grid Num er emlock Pt. Fir, 9 Couch o s Pt. v Lake Oskawana a Putnam Valley 1 — WELL OWNER Name Mailing Address GPrivate avid Gelman 229 W.78th St. NYC NY 100 O Public USE OF. WELL 1- primary X 2 - secondary 11 RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify O INDUSTRIAL 0 INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE aal REASON FOR DRILLING EBNEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION (:]REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DETAILED. REASON FOR DRILLING At present our drinking water is um ed directly from the lake and run.thru a purl ying system. We have planned for years to have a well.dug, and now ve the means to undertake it. We hope to eliminate the cumbersome no, Wrnzeme WELL TYPE DRILLED DRIVEN ODUG O GRAVEL O OTHER IS WELL SITE SUBJECT�TO FLOODING? YES X N0, IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: Address: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN .y �' LOCATI N ETCH ..& SOURCES OF CONTAMINATION PROVIDED [ION REAR OF THIS APPLICATION N SFt�PARATE E T- '(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 &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 De rtmen Date of Issue: x-319 �/ i Date of Expiration: 19 ermt Issuing f a -��7`— White copy: H.D. File Permit is Non - Transferrable 2/87 -4 yellow copy: Building Inspp- Pink Copy: Owner Orange copy: Well D--- f i 'rJ�. � arf+�+ -p'! •X t'. �,( t'yy} i a < 4 '�1y Y * � No V } ' 2 f, ,r -F+ t! . a � No V } ' 2 f, ,r -F+ i m,. a o !P # f. �r r'H r. if, All Y ��': w l < mss• �� w^ �•y ^•�•_ T, .. R L �f sMh d .• • a A - - 10.' . - _