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HomeMy WebLinkAbout3926DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.50 -1 -24 BOX 30 a _ 1,111. I .. ,7 ,, 1 r 1r ,■■�' I_ S . 1 UL f T1TO ' r IN -, '. f , 03926 $f7PO5AZ 'R 5EGE DISPO6AL SYSTFIK REPAIR OWNER'S NAME cJ 6M 4- -4 4 q iVE JA A L-Lo C 6c PHONE I -7 fO SITE LOCATION 169 TV W D V_ 12 710 MAILING ADDRESS LAeE pIi�KsK © S--31 PERSON IlQTEMEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 71 ( (&-I I q (r. TYPE FACILITY 45 i D PROPOSED INSTALLER Q � A-N- 6 C A-Y — PHONE S: L6 REGISTRATION # I' 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 fram licensed professional engineer or registered architect. Proposal a r ed Proposal Disapproved Ins is Signature & Title Date 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 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. [, as owner or reported agent of owner agree to the above conditions. )IGNATURE TITLE 1 T6 c4tc 1` DATE TI& US: White MV; ) l]aw (TuAn BI); Pink LBRl amt) DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 =ARL?i,ICATION TO CONSTRUCT `•A- "WA1PER °WELY, PCHD PERMIT O w t� 9�A� WELL LOCATION reed Address Town Villag ity Tax Grid u e WELL OWNER N e r Zffi��EG' M i Address Private .� �I�'/ �% O Public USE OF WELL T- primary 2 - secondary RESIDENTIAL O BUSINESS ® INDUSTRIAL OPUBLIC SUPPLY 0 . AIR/COND/HEAi PUMP ®ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT_ gpm /# PEOPLE SERVED V /EST. OF DAILY USAGE V al REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13-ADDITIONAL SUPPLY UrNEW SUPPLY (NEW DWELLING) DEEPEN EXISTING WELL 1A A DETAILED REASON FOR DRILLING NO 0.0-0 WELL TYPE LaDRILLED ®DRIVEN ®DUG ®GRAVEL. ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCAT A a , C G r� �` Lot Noy ® 0 C. WATER WELL CONTRACTOR: Name Address: �d IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO ov 7 DISTANCE TO PROPERTY._ FROM- NEAREST WATER.MAIN: LOCATION SKETCH SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEETS - .P (date)_ 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 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such /a manner as not to d o deegrade.r otherw' a ontaminat urface or groundwater. Date of Issue : 19 t t Date of Expiration 19 Z.l® PermitVIssuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller artI //V r% 24( IPI I_.9�K� � QLL Oi� /0. �C�' �7" {- �Ftp la.r 3� ,Cad`e� r�,��!`ar�f DepartmItt of )Vcw P®rk , Ktlaz glde'zaKil al Me Headquarters: 276 Fifth Avenue, New York, N. Y. 10001 May Rosenberg, Presidet• \z/ C- li f A J' blrllilT 1, , c 12 -37 9 , i C Daily Direct Service To All Points In States Of 'EASTBOUND SERVICE FROM THESE STATES Z. CZ_ � FOR PICKUP N.Y. (212) 267.4621 ^(:D� CALL: N.J. (201) 435 -5193 ARIZONA 'CALIFORNIA NEVADA 'OREGON UTAH 'WASHINGTON ALASKA - HAWAII PLEASANT saw Ito Col- A4 OWL 10- u O-u a ewe-) TANGLEWYLDE CERTIFIED /V .rrrr IAI ZW4- S U R v r- Y E o:. Certifications hereon are valid for Book, Ti to Co. & Owners for this transaction SURVEY OF PROPERTY FOR BROUGHT TO DATE_.__.__ only Ccit;1;cdt;ons dio not trdMtf0fdhlC to subsequent Bank, Mle Co. or Owners BROUGHT TO DATE------- All curfil;c,tions hereon are valid for this Z 04C& ­��' Ydnd copies thereo I on I y.;fsaid map nr� C1, 'tI MI SITUATE IN THE •-! vvyri w6usj ;gn.lura appears hereon. TANGLEWYLDE CERTIFIED /V .rrrr IAI ZW4- S U R v r- Y E o:. Certifications hereon are valid for Book, Ti to Co. & Owners for this transaction SURVEY OF PROPERTY FOR BROUGHT TO DATE_.__.__ only Ccit;1;cdt;ons dio not trdMtf0fdhlC to subsequent Bank, Mle Co. or Owners BROUGHT TO DATE------- All curfil;c,tions hereon are valid for this Z 04C& ­��' Ydnd copies thereo I on I y.;fsaid map nr� C1, JOHN- SALvAtdkEAOME&- copies hear lh�- impressed seal of the fur- SITUATE IN THE •-! vvyri w6usj ;gn.lura appears hereon. .. 7,-),,,,, 2F I NORTHRIDGE ROAD . PEEKSKILL. N. Y. "44 h—Ly ct,l;red that this s ... c, ..-; COUNTY p,,-p.,,,d -:,� accordance with tha ";sting Cori, of Practice f., Land Su—,%.clopiod NEW YORK 0 by the Nz- York State Associa tion of Pro. P. E. I L. S. NYS LtC. NO, 027446 1osional Land Su-0yon." SCALE, I CNC340AC14mr.NT-, OCLOW CMAOC W ANY NOT SHOWN