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HomeMy WebLinkAbout2983DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17 -3 -6 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 .-. F^ ...V -a. -... a �: �u..arra��n a�noc:,., :ate, ^: .nom °. iT� a..i'• �.�u'.. �. :�.- �.:�..wn.'4. -r -`. irti :... a± ,... -'.h '^.v- ..:- ..:r:.��..i's�. i•:: -in. e1�.:e.+: : -�.o a.« !'L :.� �. «,. 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 — I Front QP ii yP tlP I. i. �� Imo" •.�� A00 i--F02e � F F F V, - M P Z�� ,nippy (Aq( Iz- I , -L� < F �Tlbo P-2 li YJ t-y,, r 0 4 MAI P d M N a 0 M a 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. uciI-01: of owLe1 -C1�1 �iV 1.O`uaN V ::ua�av- .-�..�i. s�..n+'CV•l ;f hYs J' w. :.-... _... :._. - .. 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 0 e (V� \ya i AMN �i ;i I I I; f� N '.i is li f 1' i! 41 i. i� I: r ti i� i• t.. i! ! r� f� I , '1 i, I!