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HomeMy WebLinkAbout2956DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17 -1 -53 BOX 25 LL it . r .` 6L _ 02956 .I 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 �j Irv? of z7, 77 dry N. NORMAN: ANDERf PUTNAM VALLEYI N' (PLAY TO THE .' 'jV rJ W SEND Oak SAuppmj Ceuta -YORK Shrub Oak, NY IOU O :0 2 190 -2'3 5 21: !i'00`2 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 # �- r 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 J�l a�. 7�