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03562
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PLnNAM OOUNTY HEALTH DEPARDOW "� � , r`�
DIVI ION OF ENVIRONMENPAL AFALTH SERVICES
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DTSPOSAZ� SYSTEM REPAIR'
CHM'S NAME CT - R V-- !a PH
SITE LOCATION L'J o o S ( �
V14
. :, 10
R
aNE 5. 2 � —'IC;� a
PERSON INTERVIEWED PM Canplaint 4
Name & Relationship (i.e, owner,tenant, etc.)
DATE
j 1 `11t �5' TYPE FACIISTY --
PHONE .1' 2� C, " S"'
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.
I. }f�r/a1x6, C0C1,.-7r "/"
Proposal approved _ Proposal Disapproved
2.
3.
Inspector's Signature &
conditions:
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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.
/Date
(e,g.,house corners).
three precast 6' diem. x 6' deep
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.
SIGNkTURE �.
/ ,� [ '��
TITLE S riAt (
DATE %
PIES: Fite (PCIV; Yd]AW MlAn EU; Pink Vgliamt)
PC-RP 97
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APP LICATION'TO`CONSTRUCT AWATER WELL
PCHD PERMIT
WELL LOCATION
Street Address
:1 r
Town/Village/City. Tax Grid Number
PWrAIAW &44&-V 6
WELL OWNER
Name
W1 JM
Mailing
'FIV
Address Wrivate
J+� ®Public
USE OF WELL
1 - primary
2- secondary
P.® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP 13 ABANDONED
0 FARM 0 TEST /OBSERVATION 0 OTHER (specify
U INSTITUTIONAL 0 STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT gpm /#
0 REPLACE EXISTING SUPPLY
0 NEW SUPPLY NEW DWELLINGA
PEOPLE SERVED /EST. OF DAILY USAGE gag
® TEST /OBSERVATION El-ADDITIONAL SUPPLY
0 DEEP -EN EXISTING WELL
REASON, FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WE meja
6 er i
o /aJ w no
7U � -: 4-06A
00 M!! 1YJP1 A4i- ,TT/
S M
WELL TYPE
DRILLED
®DRIVEN
®DUG
®GRAVEL
OTHER
IS WELL SITE SUBJECT.TO FLOODING? YES 1Y NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES p�` NO
NAM OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
- -.
DISTANCE. TO.>PROPERTY - FROM. NEAREST -WAT.ER.:AtA INS.;
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(cfate5 (signature)
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.
thirt;- (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 dri operations be contained on this
property and in suc a manner as not to degrade oX_�e a contami ate surface or groundwater.
Date of Issue : 19 q,6
Date of Expiration � 19 1 2— suing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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OTHER LANDS OF
JOHN 8, ROSE MONZILLO
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JAMES F AH,D'' MARY "-+J., :.&Rl-++FFlr
SITUATE ,.IN
Rile TOWN OF PUTNAM VALLEY
. ti PUT NAM CO. NEW YORK.
C EIR T I F I E