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02956
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR )ISPOSAL SYSTEM REPAI
OFFICIAL USE ONLY
4P '0
SITE LOCATION /A// " TM# d.9 /7 d s3 �l
OWNER'S NAME PHONF{ OW �--
MAILING ADDRESS ! rZMII,01 /✓Y /0,7 9
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE <% /% D _ A TYPE FACILITY Aflrg7
PROPOSED INSTALLER
PHONE
ADDRESS 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.
I;.'as:ovu*ierg =sir- reported :agent of owner agree to the conditions stated -on this forcri.
SIGNATURE �.� GC.d TITLE w .c.. DATE
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.
Proposalapproved
/a 1
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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PUTNAM VALLEYI N'
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PUTNAM COUNTY DEPARTMENT OF HEALTH
a MKON 07 IEN R®IMEN TAL HEALTH S ERVECES
AP]ELI<CATII ®N 'II'® CQNSTRUCT A.WATER WELL _ ..... {
'please p"rmt`or type. 1 ... - :..°-I'C 11ll p erm t ## - ) ii5 -W�l
Well Location:
Street dress: - To age Tax Grid #
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Map 6—JABlock Lot(s)
Well Owner:
Name:
In&J
Address:
Use of Well:'
Residential Public Supply Air /Cond/Heat Pump I do
I- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought _� gpm # People Served ----" Est. of Daily Usage '�d r3Qal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
IDrHling
New Supply (new dwelling) Deepen Existing Well 5'A
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? .......................... ............................... ...................... Yes No _
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No—
Water Well Contractor: c- Address: �S °y
Is Public Water Supply available to site? ............................. ....:.......................... Cl Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
i)ate• fd /o A lica*nt S; natur .._.—
PERMffT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED FOR CONSTRUCTffON: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a ter well driller certified by Putnam
County. I
_ A A
Date of Issue oil' Permit Iss g Official:
Date of Expira ion _ Title:
Permit is lion- TransfenrA le
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owne4/ Orange copy - Well driller
Form WP -97
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