Loading...
HomeMy WebLinkAbout3349DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -2 -49 BOX 27 Ill"s I 1 � I _ �� T . ti ' I� I I Is Is 6 r" Is Is r,. I is ♦, . I 03349 /JO PT TNAM COUNTY 11EALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAY- S'YST'L1Vl[ `it)H;YAIf M USE ONLY 009 -d .39 %+: !iToe 1— q SITE LOCATION lit t �.^-.a •� U / TM# / OWNER'S NAME ,Jcr ::; P A-yy o �' PHONE 819S = 5-9 k— MAILING ADDRESS .2) 1-4 w p 0 - AriM m 0-416c, --I" Lo� I -0i-2� PERSON INTERVIEWED PCHD Complaint # ame & Kerationslup i.e., owner, tenant, etc. DATE 3 /% 6 TYPE FACILITY PROPOSED INSTALLER CA v..) uS CbP-Sr CO. PHONE �yd - dd -.2 YL� ADDRESS,,2.33 At&-v 14 L:? y REGISTRATION# JAG //, 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. 1�� os G i, . eav ho o o czi eyc. vile ; or`reF.Oriea a;?cnt of o,-T_cr Tree to '- Condit`On S =ted oiiAhis fr=,. _- - SIGNATURE i _ TITLE Qcl, i-- DATES 3 //J ,0 YI 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 b performed in accordance with the above proposal and conditions. Proposal approved (12p:ector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML •, 6 /3 Sep (` d Oq L3.;ra 36 13 ��, , - - : � � ,:. , 1. � - , , - " I - k s - - - £ _ � , � � ,� _.�­� . �% ,�, I . . . 3 a F - 'j� , �u ; ISO - - - t -Y F` �' 1 { (, G� , .� °;Sheet; of -� PUTNAM COUNTY DEPARTMENT OF HEALTH jb a:�"'.,F�i'iT '`..�.. i t7i'?1117�T.Nhtr`7!.J r A.;ry- ;tr1�'s �xrF`y xr" r�[�.rs rtr�. n s _ .., ,� s _. y« ae +Su'o`' !� . ��.: �2y. v4e 'tea.sn�..�r��r',..�+.4�..'�C r" "" - C S?'�. �-I _ —, L °L::.h c 3 zi``+'�ibS '�"�.:-" vsc, .'nw''' ..r 11— , yO� FIELD ACTYVI` -Y REPORT nililRFCC '44 - t Street Town � State; Zip y C �. i i ��.`� is IIA PERSOAI IN CHARGE v 4r, - r Y : 4.�WM1tS �Yj'dd!�✓I i�ir'I.; J!^t 4 Ti ti r .. -. 1. t z Name and'rtle� r a , . rrr TYPE QFI FACILITY.. , !Y. I 11 s t Z. - , _�__.- .a .,... -_ . —,.. -�. - F F t � S -x'' F' 4 r T 'M1. .YS+�. 11 '+�.»+,� ''"F)�IDTT.IYVa '� '` ra;t t "`- 'e�`v-`.- i6 _" e 9'�n�`z'xy4 ��'m�w�, s ..p-, k - t v + 4r r" ✓i S .Y '.` tK.G' K ?, r•s1 w''kM V S"Y '` -_' i��'`,Y '`t� +s 'F Y K f�lL. -��"s t�r�..FJ'+3',;Z Ja f r - yr L € i.ci`4' - + <. C _. �. y i?; :s °K 'ry '"" r« s r '`} " - ; yd k ."t. l -i`11 I r''`a, ,_ . { yr `" ; �4�`.k •4}3r"t^m4by�' { -q,. .f� rg. 1 tY - �DYj >,�.._!� f Gl.i..rla3+i� �i r..s ; r s. "�. a,� t Al s', a c ✓r Gs.��f. �Qva %+f��r�z�c is �t�5/s.%t.0 si'l S Y.`� t 'a { g - .. -� - . _. - � : IM22 " , � r , � 2 �r , , z 5 % ( ' 9 C r 11 It l t [s-° tC £o ^ ��G7.'. cwY_ c L ' � � . 11 ." T _ ark{ k Yg `` r 4 A 5���r ' _ . , r _. K ,q: a x:� "_ a �� T 5 = "". '�, �,, ,:r tee.+ - Y : k i :i�at y mz rt x b "" s -3 c u PG1 2 P ° 5x 3r z y e sk`� % - - r� _ 9r , 11 - a i x a - >Ts s. �` # a . s r talk "_'�' :. a y, P. ,G s x -_ s s " s c as ;r P` ets su, ' ^'f >.¢ , '. i „Y A .� y,f3. .$' . - _ . r t �- ..c . "';, s '' t-�":. i °Uu. i fix'` . r : a �G .� �a, I, s r� . -ice!, . `� 4 k �' =gsrt ,�a�� . -. , � ' �T�L., - IGT_Q I; - � TFT' _ i + 8 aq a Signature and Tale _' - ' 9 _ -R FP(1R T RF(`FTUFT) RY•- w L -. I :acknowledge`receipt of this report SICrNATURE; z> lil 02 </ 96.. - Title,._ - . 11 _ PUTNAM COUNTY HEALTH DEPARTMENT • , DIVISION OF ENVIRONMENTAL HEALTH SERVICES I: ' .=. �. ..., :*-: ".. -.+, .. - .. -. �+:�fyyfpp� �}i�� P ,. .- �i�°-.�- •.-�.��� n w ya.�m i .p.�d�y ^n T i ppJ_:_�tiC A� L•i{F��'t��(0 "v` 'LJl4�i.'• vii �Gm � MoV �`ei id �ia'Mad�' ��b ®�'�D d �i�qB ��r �1 I��S�il I min L�LSq ® ,Z Repair Permit Issued In lest 5 years ❑ ❑ Repair within BoWs Comers. W. Branch or Canon Falls Reg. ® © Repair within 200 R of a watercourse or DEC - mapped wetland SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT Not in Watershed ❑ Delegated 1:3 Joint Review V- .011ez Tit # A,, +To edj:nea PHONE# hr T Name & R atiortshfp (.e,, owns , !anent, contractor) DATE FACILITY TYPE S / ® PCHD COMPLAINT # PROPOSED I FALLER C'4r-0 >US CO PHONE # —,Fa) 6 - � L ADDRESS C o - ,Lh rfajje r 2d iZ� t. REGISTRATION /LICENSE # f C &gK Proposal (include a separate sketch locating the house, property lines, all adjacent wells within ZOO feet of repair and the location~ of existing and proposed trenches) `" I�d't'>T °RL Sdil"PHtist 6e ih- came location and of sarrl'ia type as orlolhAl age disposal'system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. n _ �s• _ w- .....rte . , I, as owner, or reported agent of owner agree to the Conditions stated on this form SIGNATURE ��- 1 /4�� TITLE /�.�►..� airs CO,-t,.Cr C4 Proposal ap rayed wish the following conditions: 9, procurement of any Town Permit, if applicable. ubmission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street game, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gel. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in jiccordance with the above proposal and condition P o osal An wed Proposal Denied r4p injs�eeoLrs Signature & Title Date COMES: White (PCHD); Yellow (Town BI); Pink (installer), Orange (Applicant) PC -RP 99ML DATE DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 `�°'�,r�j.,`"�1�.:r;I'1`�'i" �%'Gi�i``"�"`WFa'i•'�J� "'ii�sp' Ifi'Z- PCHD PERMIT # WELL LOCATION >.,., Street Address Town Village City Tax Grid Number WELL OWNER Name LTH,iVL A} LNoPs%>-S�R Mailing Address rivate • 3 µ, l}U �f, �lr�u,w.., vk A/,-( /v3'7`t 0 Public USE OF WELL 1 - primary 2- secondary ''RESIDENTIAL- 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP' 0 ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify b INSTITUTIONAL O STAND -BY 0 AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 2 /EST. OF DAILY USAGE__gal REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING ) CI DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING I S'i SIS4 I &dl 1 -i-00 S (,,,1(0%,0 WELL TYPE ®DRILLED []D.RIVEN DDUG []GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot'No. WATER WELL CONTRACTOR: Name Vp9-1 / nOU,6 ll-S.-b hJ Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1C NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY A7,1 1ZE eTu�;I?�.Oc E r..M -AK 4,b - it .i�_ LOCATI N SKET SOURCES OF CONTAMINATION PROVIDED N SEPARATE SHEET cuol 1;' 01�j "1 te) t (signatur 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 dril operations.be contained on this property and in such a/manner as not to degrade or of erwi a contami to surface or groundwater. Date of Issue: 19 Date of Expiration f 19 Permit Issuing fficia Permit is Non- Transferr le White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller i �� 1.1 � ^v.♦ r %�� � �- •`�' • A> 00 ^-9 \ V yASON4y ;ydAL�- A.. r �p PAT /O a'2 t ), 1 S7TONE FROMT ; 3 d CONCRETE TORY _ _ ,..�.vs•RY sroivE yyAL�- � FIQ��E- f- /oU-SE rr o L O T 22 P� '�coC- ` o p c rlO \ 5770"c y�.4 L m : afeP3'o/vKY A f�(i y Tt1 M Z-07- L07- 24 L OT G A4 "'At z PA T/ 0 74' t• CONCRETE RATIO . STORY sroMe w` comc P,4'rlO 'dr WAl- ,ew ..fASVIV'qy . 1 0 'Pro o-r 24 or I ? LOT 495 1h oa(A L 07- 2 r itj c(di Vt V 7 70' $ TAKE 7 L07' 51 L Or 52 OF PPOPE P T)01' a PREPARED FOR W�/ ��yL /AM &Z tSAFKA, CIR. 6 ro,4 To /v r9E, � , >N OIL' PUrNAM VALLEY PeI7-1m" COUNTY A LA PI DATE NOV. 9� 1972 -,q oa FILE -67CA-3 . NO. 7 m llf*� �,.. Aye ..., �,. c':;, 0,:•: e3.: s�"a:ag;.�risn:>'�-zd•�a."iiei*c s;.vc"s -e"�n �m' i�,:% �':is:i:;:�was= �.3.,,;.."�:..:d •.- aw: C.: ti�S' a, �; e�':= s+ r�ira'•." PfT .'•W76P'afa^�iAl4Tr••'..� -t'd_. .•x.TPRR_4'_A:'�'..,,.. a ' ® t - +t sj•�5, t 37.64 s r, a rU z � of i ` s � 7 P DES 1 LOT 22 ,3 LOT 29 { z - «__ /f~Yi �si^w "I wFC4+r i.im _gyp 0rwsN^x.w we w.�prg4 �SC. b � u" r h OF STONE �• �.��� i STAKE K LOT 56 LOT 55 LQ7°754 NOW OR FORMERLY; N1 - 1-1L7EM 15ES SHOWN HEREON BE' 11V6 LOTS 23, 24 AND 25 AS SHOWN ON a`7 AMENOEO MAP OF CAMP LOOKOUT. cj S 1 0 MAP F ILED /A/ THE P(JTiVAM td CO(JNT Y CLERKS OF'F /CE ON a s c/r4/V• 30, 1930 AS MAP N -° 12 1A. � I .; SURVEYED & PREPARED BY nu"` ALEXANDER BUNNEY a, "Na'sry LAND SURVEYOR. P.C. ..,..,,, ..,•.,;,,,,, gMa+uftir+y 'I 20 WOODSBRIDGE ROAD .I rt •rve.t s-..m t a�•Ie ws KATONAH. NEW YORK 10536 ••'•'' �"•� to V' Ifd' ♦,3 �' J. Sri `` ° �- �G�sd?2 t� �.w.. -•Y� _- _... - -- SURVEj ED�. sxv aN r 5 LIC No 28894 ;n0N AR0a$UrIQ'fYC Nf "f `r " 40297 - ,y, 91 Elm, -