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03777
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAr; SYS EWEEP
OFFICIAL USE ONLY
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SITE LOCATIONfl TM# I 1 7
OWNER'S NAME PHONE 5- —e2-65'
MAILING ADDRESS
6M
PERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc.
DATE `7
PROPOSED INSTALLER
TYPE FACILITY OVO>
PHONE -6-2- 6 ;;Z595-
� � Ey, Jq �- REGISTRATION# /
ADDRESS �'F'i' �rr�� M Q-L L
I V
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.
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I; as owner,-or- eported agent of 9,,yp agreeao .he conditions stated on- this - form,, --
SIGNATURE . - - - N TITLE �� G_ .. _ . .- DATE , h 3
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 be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
PU NAM COUNTY DEPARTMENT ENT OF HEALTH
7 IlDIfV SffC T 07 IENWRONM EIVTAlL HEALTH S ERW CIES
APPLICATION TO CONSTRUCT A WATI7E�IR WELL � y _
Well Location:
Street Address: Town/Village Tax Grid #
Map
Block Lot(s)
Well Owner:
Name:
Address:
r- S .'r- K, 13 U
VQ C t/_ 6ix7- LN. 9' q -rx ig
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Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
I- primary
Business Farm Test/Monitoring
Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield ght :5; gpm # People Served — Est. of Daily Usage ,e r gal.
Reason for
Replace Existing Supply Test/Observation
Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Q 'e
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel
Other
Is well site subject to flooding? ................................................. ...............................
Yes No
Is well located in a realty subdivision? ...................................... ...............................
Yes No
Name of subdivision
Water Well Contractor: Al. _,6&jiE'f2SoA1 Address: /si' -�'
Lo No.
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Is Public Water Supply available to site? .................................. ...............................
Yes No
Name of Public Water Supply: Town/Village
Distance to property. from nearest water main: 9 1%�i- �
Proposed well location & sources of contamination t6-be provided on separate sheet/plan. ; - R $
Date: Signature:_._:
-
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
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APPROV EID.FOR CONSTRUCTION: This approval expires-4w& years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified by P am
County.
Date of Issue 1 , Permit Issui g Official: -
Date of Expiratio 1 i' oz_ Title:
Permit is Non- Transfferralbl
White copy - HD file; Yellow copy - Building I spector; Pink copy - Owner; Orange copy - Well driller
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,Sion of Environmental Health Serviou. �' / /,!�) '� �' � I,r' c:W0,C q TY
approved as noted for conformance with
1pplicable Rules and Regulations of the For
Jut Z ty
Ti 9 0 ROBERT BRADY
S/luale in
TOWN OF PUTNAM VALLEY
PC/ TNAM COC. N T Y, IVY
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