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OWNER'S NAME I/ 01z---1
PUTNAM COUNTY HEALTH DEPAR'II4ENP
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL SYSTEM
SITE IDCATION
MAILING ADDRESS f�c/
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, aaner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLM— / w ,•`�� �
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PHOLJE
REGISTRATION #
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.
Proposal approved
Inspector's S
tune &
Proposal Disapproved
Date
!roposal approved with the following conditions Ol
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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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 DATE
6,!001114
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
y PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME Peter Miller PHONE 914 - 528 -5577
SITE LOCATION Park Street, Putnam Valley, NY TM# 114 -3- 4,5,14,15
MAILING ADDRESS R -..D , #5:, Os_ cawan,aLsa`ke'Roa'd.,'P.utn_arn V�a111zey NY10579
PERSON INTERVIEWED Owner PCHD Complaint #
Name & Relationship (i.e, owner, tenant, etc.)
DATE TYPE FACILITY SSDS
914 =528 -5577
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.
Rpplacp existing 550 gallon septic tank with new 1250 gallon septic tank.
Septic tank shall be precast concrete and set on a.minimum 3" bed of pea gravel.
All work and materials shall be in accordance with the rules and regulations of
the Putnam County Department of Health and the Town of Putnam Valley.
Y
I, as owner, or reported agent of aWer agree to the above conditions.
SIGNATURE TITLE P. E. DATE 4/30/87
X'IES: Mite (P D); YeL'loia (Tan 'HI) i Pink (APPUCant)
Proposal approved Proposal Disapproved
Inspector's✓ Signature & Title
Da6e
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 camponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
(e.g.,house corners).
three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of aWer agree to the above conditions.
SIGNATURE TITLE P. E. DATE 4/30/87
X'IES: Mite (P D); YeL'loia (Tan 'HI) i Pink (APPUCant)
JAMES J. HAHN ENGINEERING TEL. 914- 279 -2220
RT. 6, R.D. 1. CARMEL-BREWSTER RD.. BREWSTER, N.Y. 10509
Mr. William Hedges, Jr. RECEIVED
Putnam County'���``I�` "�
Department of Health
110 Old Route 6
Carmel, NY 10512 °$7 IiAY °4 P 2 'S 7
Re: SSDS Repair for Peter Miller
Park Street, Putnam Valley, New York
Dear Mr. Hedges:
Enclosed for your review please find one proposal for
SSDS repair, two "as built" repair sketches, two sets
sketches of the proposed addition, and one copy of the
property survey for the referenced project.
The proposed addition will not increase the number of
bedrooms, however, pursuant to your discussion- with the
owner, the existing 550 gallon septic tank will be replaced
with a new 1250 gallon tank.
Your timely review would be much appreciated. If you
have any questions, please do not hesitate to contact me.
Very truly yours,
Ken
iimfzu
KS:mh
Enclosures
E N V I R O N M E N T A L A N D C I V I L E N G I N E E R I N G
STUDIES REPORTS DESIGN
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RECEIVED
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'87 MAY 4 P 2 :57
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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APPLICATION TO CONSTRUCT A WATER WELL
please print or type PCHD Permit #
Well Location:
Street Address: Town/Village Tax Grid #
l V �� o �, /Do.- ff .��! • %.,�y Map'? f Block % Lot(s)S-2,
Well Owner:
Name:
Address:
`
sr / / { , 11P �l ®
I '1q Q'�'
e of Well:
>< Residential Public Supply Air /Cond/Heat Pump Irrigation
rimary
Business Faun Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served' —5— Est. of Daily Usage ee"ClW gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) iK_ Deepen Existing Well
Detailed Reason
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for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yeses No
Is well located in a realty subdivision? ...................................... ............................... Yes p4 No
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available to site? .................................. ............................... Yes Nom
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date:." Applicant Sig.>ature:.���r°�
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.
APPROVED. FOR CONSTRUCTION: This approval expires two 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 Putnam
County.
Date of Issue / Permi
Date of Expir io cv Title:
Permit is Non- Tranife rable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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FOR ASSESSMENT PURPOSES ONLY
REVISIONS
I SPECIAL DISTRICT INFORMATION
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NOT TO DE USED FOR CONVEYANCES
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JAMES W. SEWALL COMPANY
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147 CENTER STREET, OLD TOWN MAINE
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