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03523
PL]TNAM COUN'T'Y HEALTH DEPARIMERr
DIV.LSION OF L",LIRONtM"AL HEA1_- .'H SEWIC S
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
Tr e v a s
PHONE
528-8148
SITE LOCATION
3 Arrows -Tulip tree La.
7W. /.g°
MAILING ADDRESS
Putnam Valley,N.Y. 10579
PERSON INTERVIEWID
owner
. PCHD Complaint l
Name & Relationship (i.e, owner,tenant,
etc.)
DATE
9-92 TYPE
FACILITY 2
b r d. r e s.
PROPOSED INSTALLER
Valley Excavating
PHONE'
245-2276
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.
Install 8 infiltrator sallies with stone between
existing septic fields.Replace existing pipe from tank
to gallies with sdr 35.Install new baffle in existing
tank.Gallies to be in 2 rows of 4.
Proposal approved
Inspector's Signatffre &
Proposal Disapproved
r000sal aoaroved 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
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' diam. 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.
RAY
MM: v&te (MD); MAlcm, (`klal HE); Pink (k#iaint)
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DEPARTMENT OF HEALTH
Division Of Environmental Hq]1 Services
TWO COUNTY CENTER — CARMEL, N.Y..10512 (914) 225 -3641
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APPLICA N TO C NS T A WA WELL
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
LOT NO.:
WATER WELL CONTRACTOR: N
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC -WATER SUPPLY: - TOW-N /V /C
_ .. DISTANCE TO PROPERTY— ?R1b_k1 ` N T' �AtE' R .1-MN
LOCATION.SKETCH & SOURCES OF CONTAMINATION.
(date) 1 (signature) f
-
PERM IT
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.
Date of Issue: 19 Cb ,
P rmit Iss6ding Official
Permit. is Non - Transferrable
J)6 0
STREEI AUGRLSS.
iU iVILLAG'E /cllY 1AX ViU NUM6EA.
(�
WELL LOCATION
T ( i b
WELL OWNER
NAME..
Ao AESS:
� �
PSIVATE
LpUSLIC
E OF WELL
&RES IDENTIAL
0 PUBLIC SUPPLY O AIR /COND. /HEAT PUMP
0 ABANDONED
primary
O BUSINESS
O FARM D TEST /OBSERVATION
D OTHER (specify)
2 - secondary
p JNOUSTRIAL
O INSTITUTIONAL O STAND -BY
13
MOUNT OF USE
YIELD SOUGHT
'S gpm. /NO. PEOPLE SERVED /EST.
OF DAILY USAGE " gal.
REASON FOR
NEW SUPPLY
U PROVIDE ADDITIONAL SUPPLY
0 TEST /OBSERVATION
DRILLING
gEPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
WELL TYPE
DRILLED
F_� DRIVEN E] DUG GRAVEL E] 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: N
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC -WATER SUPPLY: - TOW-N /V /C
_ .. DISTANCE TO PROPERTY— ?R1b_k1 ` N T' �AtE' R .1-MN
LOCATION.SKETCH & SOURCES OF CONTAMINATION.
(date) 1 (signature) f
-
PERM IT
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.
Date of Issue: 19 Cb ,
P rmit Iss6ding Official
Permit. is Non - Transferrable
J)6 0
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PU1 -`PXU 'Y' HEALTH
- ". . —+v 1t ..r�..ti' •:' v.`
DIVISION OF ENV�ENrAI HEALTH SERVICES
John M: Simmons,
Deputy.. Coimnussioner of Health - ,.,FIELD:-ACTIVITY' REPORT = . `:'
Sheet of
t�
�AME (, `i��S JC,
INSPECTION
l
Orig. Routine
- fi- (1 %
(l
Orig. Complain
ADDRESS,(. p 1
Orig. Request
No. Street -Town 'IlK: No.
Canpl iance
. ,
n/�''i
Ala in t
-MAILING ADDRESS
. (.:� �. � �
P %� ems. $� ` � �
-_ Final
P.O. Box Post Office ,Zip Code
Group Illness .
,
TELEP�iOI� ` 7i f 2" Z z z, ° 7�2: 2i - Z3s 77 Z f�k,L
Construction'
`
Reinspection.
PERSON IN- aiARGE - -
�j
r . '
° Field, ..Sampling Only
14
OR . IDFI'ERVIIIeTED +1. _.� Yr
.Field Conference
Y .
Name and�Ti.
,;r...
-PATE /d
Other
TYPE FACILITY
TIME ARRIVED T?N1ME LEFTS %4.;y, y
- s
Explain
FINDINGS r.
;
CS
V iy
PERSON am OR ,INZ
;,.I-acknowledge this Fiel
6%86