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03304
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PCHD Complaint #
DATE A y S. n3 5 A: TYPE F.
PROPOSEDINSTALLER
PHONE J ��$ �"��_ 6(,1.1
REGISTRATION# JOC h A.2 -/;
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.
`0 ,� cN S-� f�, \\ �' C' 7 t e\ us.
as- owner,.or.r ported,agent:of owneragree.to the cort_ditions-sstate_d -on -this- form:
_ SIGNATURE -- _ t G7 TTTLE �% J'' /` C-10 e-
Proposal approved with the following, conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
DATE
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 be performed in accordance with the above proposal and conditions.
Proposal approved
3
4pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
k7d;zl i-xum Santos Country Store TO 2787921
i L - L
4! 1
Wol
P.01
9
reLnir must ba in am* lomtion and of GM tyPe as crigiml m*ge dispowl aystwa.
Diffexent lomtion may require bubmittal of proyml frcm licmoM prozessAaml wgimw or
raq#tered ardhitect.
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X, as 4pmer" 4w
BIGN-mm
TOTAL P.01
OWNER'S NAME
SITE r1JWION
MAILING ADDRESS
0
go, da, mm, ., i� . •iy tip• w�.
Rg(-'?e
55 z- - / C)
I PCHD CaVlaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
t PHONE J I
REGISTRATION # - -T
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 fran licensed professional engineer or
registered architect.
-
Proposal approved V - Proposal Disapproved
Inspector's Si nature & Title to
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 canponents 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
SIGNUM
owner 'pgree to the above conditions.
XP16: Write (PCFD); Yellow (fin HU; Pink
PC -.RP 97
TITLE
Q;1TE � S
/
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
:� . -. :.S R .fAi.:. ,;.g.*p -gin• -r.— T.: �'�:,.:., rl -.-:.
WATER DWELL A� .
PCHD PERMIT"
WELL LOCATION
Street Address T wn
age C ty
x Grid Number
WELL OWNER
Name Mailing Address
.4 Y, 0 s S' a+/�O
ivate
Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL 0 PUBLIC SUPPLY
BUSINESS 0 FARM
® INDUSTRIAL 0 INSTITUTIONAL
0 AIR /COND /HEAT PUMP 13 ABANDONED
0 TEST /OBSERVATION O.OTRER (specify
0 STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_ gal
® REPLACE EXISTING SUPPLY ,® 2- EST /OBSERVATION 1 ADDITIONAL SUPPLY
0 NEW SUPPLY NEW DWELLING W DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
r _
WELL TYPE
DRILLED
®DRIVEN
®DUG
®GRAVEL.
®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X\ NO
IF TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
J Lot No.
STATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ZY_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE-TO PROPERTY.:�RCM: N&MST .WATER MAtN _
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
g1ly(eil DON SEPARATE SHEET 2a�4 —,
(date) (Sig at re
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
thirty (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 and all water or waste products from such well drill operations be contained on this
property and in s /V 19 manner as not to d egrade or oth wi aminate s face or groundwater.
-r
Date of Issue: 6 ( 1981 d S
Date of Expiration 19 Pe it Is uing OAficial
Permit is Non - Transferrable White c`6py: HD File - Pink copy: Owner
3/89 . Yellow copy: Bldg. Insp. Orange copy: Well Driller