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BOX 25
02983
�►� BOG DEPARTMENT OF HEALTH
J �a Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
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APPLICATION TO CONSTRUCT A WATER WELL S 9�
PCHD PERMIT
WELL LOCATION
Street Address
sr Vt
Town Village City Tax Grid Number
t
WELL OWNER
Name
UQ7- • C $
Mailing - Address QPrivate
(n5 l-6& 15V6406 P OTAIAM VA t-LE O Public
1SE OF WELL
- primary
2 - secondary
,KRESIDENTIAL '
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
b INSTITUTIONAL ❑ STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE SERVED ,3 /EST. OF DAILY USAGE] a
REASON FOR
DRILLING
REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION M ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING XDEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
N Qo
.r
WELL TYPE TYPE
DRILLED
11
DRIVEN
ODUG
GRAVEL • D
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �-C)p,edUT 1)?nffV
Lot No. q3- 9 y
WATER WELL CONTRACTOR: Name Klyk A' tgNDt-iLS0AJ Address: PorIy th VAi t-.64 _
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DIS�ANCL�- 1`O�ROP����OM"NYL�S�•WAT�It MAIN:- ��%' j
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
❑ON SEPARATE SHEET
Z7-A'
(date) (signatures
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
thirtT (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 atd all water or waste products from such well drilling operations be contained on this
prop city and in such a manner as not to degrade or otherwise eentaminate surface or groundwater.
Date of Issue: Ls�� ----12 % 19
Date of Expi"33tion 19 % Permit Issuing Off '
Permit is Non - Transferrable White copy: HD File.' Pi copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
I
41-1
Demchak, Joyce Map 8-18-06 — 39 Starview Avenue, P4tnam
Valley, NY 10579
� Four rows of 10 infiltrators each
DBox —
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In an effort to make sure you the customer is aware of all problems that can
arise when we start digging, Mr. Rooter has created the following list. All of
these issues are unforeseeable until we start digging.
o Any and all underground impediments ( i.e. rock, water etc. ) that result
in additional work will have an additional charge.
o Any shoring as required by OSHA will have an additional charge.
o Any special requirement by the municipality, sewer department, water
department etc. will have an additional charge.
o Any additional inspection fees charged by, the municipality, sewer
department, water department etc. will lavean additional charge.
o Hand digging to expose existing utilities will have an additional charge.
o Any jackhammering or additional excavation equipment will have an
additional charge.
o The repair of any utilities necessitated by the work being performed will
have an additional charge.
=ceyw�f', ;li 1J. ruS�, C►::C 1J�P, T_ ii ('j:;t ^;�r1Qt1.1`.li()TyL�3�:` ___ _.� �._ _ _._
responsibility of Mr. Rooter Plumbing
® Unless otherwise noted backfilling is to machine grade only.
Please make sure to discuss each issue with your technician as it may pertain
to your individual job.
Q Aost6a a 1/9
Custo er signature Date
Technician signature
P.O. Box 1740 o 75 West Road - Pleasant Valley, NY 12569
1- 800 - 795 -9003 - Fax (914) 635 -1173
a.
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL-SYSTEM REPAJR
SITE LOCATION 3q 5
OWNER'S NAME TO�
MAILING ADDRESS 3q a57
TM#
PHONE
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc. .
DATE
TYPE FACILITY
PROPOSED INST LER / PHONE—,WY-6 3S d Y'
ADDRESS —;5- e$ REGISTRATION#
'oop7f
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.
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TITLE DATE A/1
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 comers).
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 erformed in accordance with the above proposal and conditions.
Proposalapproved
Cpector's, Signature &Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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