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Home My WebLink About3071DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.26 -1 -43 BOX 25 lirs Wo ■ �`� 'INN. 03071 a. PUTNAM COUN'T'Y HEALTH DEPAR'IlMENr DIVISION OF ENVIaa1MgEAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME i� 3 i L L t A %tit 0 SITE IACATION _ 141 rWF -t4 a H A N RD NG MAILI ADDRESS rC h li!M &u-X � RD PYTH, PHONE $-2-� - ZRS- ��L PERSON INTERVIEWED ik-U t b" OW 0 PCHD Complaint # Name &Relation ip (i.e, owner,teriant, etc.) DATE J'r L (c p S TYPE FACILITY PROPOSED INSTALLER PHONE 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. 5 / I • tl�o - G 1�� • 15 �ZS 7V �� 1 NSilk �. f./F_ F� 6rAz-Wk L. - W J'r 14 NOW DI ST9113 v 11ON [.40A FF CP 1 N $ arr� - C791.6- - 5Y5r-'5, A .0 New ADP O& Proposal approved 's Proposal Disapproved & Title 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 drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported ag t of owner agree to the above conditions. SIGNATURE TITLE Q(1� �,I (,�t�✓ DATE -� 48 .MS: V&te (POD); Yellow (fin HI); Pink Lkl2laant) JAAP 19F ?9 ®P®'5F-r2 Prd(-° �,yowy. Wrt4®NAN 11 � C � WOO y a 'a ,9 O' ® a day ®-,� �I li t r; �I i OYO ooil �� f i7.� ®tea fa ,5" /hD VI R0 -CNA,�&i551Z S .SF,-r Im 14 a afr—RA1VF,&=- w 94 He- 0 9 5.r OCA r- ,O 616- Grog' 69d& & �B s / —3 com ROY 10a,> 6 ® I NJ o® t r; �I i OYO ooil �� f i7.� ®tea fa ,5" /hD VI R0 -CNA,�&i551Z S .SF,-r Im 14 a afr—RA1VF,&=- w 94 He- 0 9 5.r OCA r- ,O 616- Grog' 69d& & �B s / —3 com ROY 10a,> 6 ® I NJ o® PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL n!ease c C t:URe; .Pnt?nl Well Location: Street Address: / g To illage Tax Grid # t I '1 \7.,ti✓�._. Map 624 Block Lot(s) V3 ,,h.,,d_, Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigati n 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought ;` gpm # People Served - Est. of Daily Usageal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason - for Drilling L4 A, -v 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: �1&'z (/�,Z&�, a..,_-Address: 1-..o ,-- Is Public Water Supply available to site? ................................ ............................... Yes No Name of Public Water Supply: Town/Village G Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: Applicant Signature: f-� -'' ^� -= ice• --% ��-�-- - -'w-, A 64 L Am PERMIT 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 CONSTRUCTION: 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 water well driller certified by Putnam County. Date of Issue Date of Expiration Permit is Non - Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 9, ,) 1 Nw Sµ% PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ]ENWRONMEN ['AL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # A v030- as' Well Location: Street Address: J TownNillage / Tax Grid # �Z4_ry a �r�► �. , >�Map6-1,11P Block J Lots �3 IL �� Lot( s) Wen Owner: Nan ! Address: Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth ft S Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned I- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For ff W4.Q)- A--o Abandonment: Description of Work To Be Perffor>mned: M�' Ltj i4� C11wC'r_J9__. ti Date: o �� I / / C.. /j� Applicant Signature: h�''r -I� I PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam f County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. ' _ 1 •fin , Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 r / i • \' , � \ - _ .. - - — it s •i ' i ob at •n 'ISX V A.1 50OLF Or- cm IV lit Air NO V4 G LI-6 L, All ev LOW SCALE -D' - ' � AREA MAP ' SITE LGGATIGI .~ NORMAN ANDERSON INC 152 BARGER ST :.._.PUTNAM VALLEY. ._.N .10579_._.___ Bill To CAROLI GABRIEL 41 WENONAH ROAD, PUTNAM VALLEY, N.Y. 10579 1917-304-4829 Invoice P.O. No. Terms Project Quantity Description Rate Amount PUTNAM COUNTY WELL PERMIT #155 8/21/05 COMMERCE BANK 11000 ATRIUM WAY MOUNT LAUREL N.J.08054 TOOK 8/24/05 NEEDS TAX MAP NO. &V-, y-(o °- l -'f 3 #155 8/21/05 $150. 150.00 150.00 Total $150.00 NORMAN ANDERSON INC 152 BARGER ST -ALL7�U - .---.---PU-TNAM,.V 'y. j 0 Bill To CAROM GABRIEL 41 WENONAH ROAD, PUTNAM VALLEY, N.Y. 10519 1917-304-4829 Date Invoice # Terms 3TZCO-1785 8/24/2005 P.O. No. Terms Project Quantity Description Rate Amount #155 8/21/05 $156. 150.00 150.00 TOW $150.00 le k . -rZ -tom Wf Ir fit Vq. //e : r d 4 ve B �° ...w oo f or OWT AT Jre C fir NORMAN ANDERSON INC 152 BARGER ST Bill To CAROLI GABRIEL 41 WENONAH ROAD, PUTNAM VALLEY, N.Y. 10579 1917-304-4829 _ Date_ -invoice # 8/24/2005 I t 3400 -1785 I P.O. No. Terms Project Quantity Description Rate Amount PUTNAM COUNTY WELL PERMIT #155 8/21/05 COMMERCE BANK 11000 ATRIUM WAY MOUNT LAUREL N.J.08054 TOOK 8/24 /05 NEEDS TAX MAP NO. 62.26-1-43 #155 8/21/05 $150. 150.00 150.00 To Q $150.00 O A� - '79 e 4 k/illn T�z \ qq lv rWW-1 O O ON N E*Q ON O