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03364
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03364
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• ILIPA IRJ • z Kk ZA R i -t -H -W1 Ma.
OWNER'S NAME �� Z2- 0 t, -3/ �' e, PHONE
SITE LOCATION / % Q _ -_ - o �. °� TO
MAILING ADDRESS
/V C -7o
PERSON INTERVIEWED Pam Canpl.aint #.
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE _;Z � � � 2 Z 2
Pro (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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Proposal approved Proposal Disapproved
C%
Inspector's Signature & Title Date
r000sal amroved with the following conditions:
1. Procurement of any Town pemit, 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE PATE 741/9-0
FUS: Vbite (PCID); YeUcw (Ttvin ffi); Pink (Anlimnt)
52
Riuritimi 6 rRAINIG
SEPTIC SYSTEMS, DRYWELLS, CURTAIN DRAINS, WATER LINES
P.O. BOX 1240 HOPEWELL JUNCTION, NY 12533
(914) 226-4223
Paul Hendrickson
19 Tyler Road .
Putnan Valley, NY
Installed: 3/9/90
Permit # R-2690
Replaced 750 Gallon concrete block septic tank
with a 750 Gallon steel septic tank.
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SURVEYED -& PREPARED BY
UNNEY ASSOCIATES
ENGINEERS & SURVEYORS
156 KATONAH AVE.
KATONAH, NEW YORK
N. Y. S. LIC. No. E8994 /
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SURVEYFfJ AS IN POSSESSION
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s. ICC.~ O�l Ow. w�' iv+ a�-. zMT. 4+. i» r�Cl r�: t�f"+ e^ � :1..,��.- s�.^.+�.u>.•a'�°,!tl:L w`.a¢c
MARVIN O'DELL
Inspector
-TOWN-NAL-.�.- .�'.
Ve.iwaA ,.a}sjYC.aa�Qa :+\:.1W�1:a9��I .�"T.�� Y{j� �WU.••�,�a C. �^.n,6.::�0e�,�,bW. >,
Pl!`TI�A�ill VAL�L'�ir, N.Y.
(914) 626 2377
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY. DEPARTMENT
Robert Morris
Dept. of Erie. Health
110 Old Route 6 �
Carmel, N.Y. 10512
a
August 10, 1987
Re: Proposed Well - TM #61 -1 -10
Adie - Peekskill Hollow Road
Dear Mr. Morris:
The proposed well shown on sketch drawing submitted conforms
to the requirements of separation between any SSD system and,
therefore, would be approved by this Department for construction.
Upon completion, a copy of well drillers log and water analysis
report shall be submitted to the Building Department by the
owner before the well is put in service.
MOID:es
Very truly yours,
MARVIN O'DELL
Building Inspector
DEPARTMENT OF HEALTH
v Division of Environmental Healtb Services
rWO COUNTY CENTER - CARMEto N;Y, 10512 (914) 225=3641
.see ^. 4,.:- ��,T.�;__ c ��. _� .*aa .rr m iN�.... .�• rew s. �N �._
th]�lCATIdN .TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Address Totft Vil age City Tait Gri Num er
eld ..... _. _ l _- 6._it1._..._.._......_
WELL OWNER
Name,
cling . A i`es i ®5 riVate
®��.�/G_. i.%�C.� , eaTid�/!i. fit
USE OF WELL
1 - primary
2 - secondary
JYMSIDENTIAL
0 BUSINESS
INDUSTRIAL
0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP b ABANDONED
O FARM CiTEST /OBSERVATION 0 OTHER (specify
0INSTITUTIONAL ❑ STAND -BY
AMOUNT OF USE
YIELD SOUGHT
S ..._ gpm /1 PEOPLE SERVED /EST. OF DAILY USAGE,_., / __gal
REASON FOR
DRILLING
- NEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY EKEST OBSERVATION
PLACE EXISTING.. SUPPLY _� DEEPEN...EXLSTING WELL __ __ _ _. _ .._ ......_._._.._.. _.....
DETAILED
REASON FOR
DRILLING
_ ®6 aiz 8A CA
AeAgss SM" -r.. �y- ot/ Vi=e FOB
WELL TYPE
29DRILLED
DRIVEN
DUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? __,,_YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUADIVISION:
Lot No.
WATER WELL CONTRACTOR: Name A1#AoY&W 14#DQ1 S M _ Address : AAWS"f. AMAN
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO c
- �
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY `m
b 'lE4iv` 9 TO f'1tOPERJ°Y FRONT NEAREST WATER -RAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION , ON SEPARATE PEET
date) (sig ture)
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 5.0f the New York.State Sanitary Code; and
provided that within thirty (30) days of the completion of water well construction9
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
County Health Department attached to this
3.. Submit a Well Completion Report on a form
Health Department.
Date of Issue: 5-,20 19 b -7-
Date of Expiration: 5-dd 199
requirements of the Putnam
permit.
pr ed by the Putnam County
�6 r-
eemit Issuing Officia
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2187 Orange copy: Well Driller