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HomeMy WebLinkAbout4086DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.72 -1 -28 BOX 31 �■ �� 1 , % .. I - ;, - ' 4 Il PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES , PROP091143.�El�A�E TREATS != S E: �- .. _L:tII.S__i YES N-01 Internal Use Only PERMIT #Z' ❑ 17 pair Permit issued in last 5 years Ot In Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. IT Delegated 6- V ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION '� L -I 'L _ nJ4 � 171 IV ,^ TOWN � 11 � -� ll k J�TM # ,3 OWNER'S NAME MRS i4a M PHONE MAILING ADDRESS APPLICANT Y11 10_ ).l uMoyl Z 1,4 R T IA w0 �- KS L.LC Name & Relationship (i.e., owner, tenant, contractor) DATE 1 1 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER Tn N f- t,� rKrd 1HONE # 7 q.S , 4 7.S - /q ADDRESS �v y, 12 14 m 1 t3,L4 �;�_ REGISTRATION /LICENSE # 1 ` Proposal (Include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE TITLE ©L,,L/tce, DATE y (owner) -- _ -_ l,.ttto.Ae- fic-,n •sWier;_s -gr to cmm�ly with the conditions 'of this.permit for.th,; - -ss, j� ,, �;;�t4r, 4e ais : - . p SIGNATURE TITLE DATE -yl I y/// (Installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, If applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Approved Iff Proposal Denied ❑ RX2_ P� 6�,,y 20/ Signature & Title D e is in compliance with applicable codes Yes U No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 8 AiD t,,,- go LOWY. F7- -7---,q 0, 0 % go LA�l uksalll I :.::.:.,,:.,... w...-...,.+,...,...: o.,.,...,.:,. r.,... a. mi:... a..: s+: nscai,:., ��. , rrmu:. s..w.i.�xacu.uuc:u:.+u:r'..:.u� u�e,to:.arve.ruw.m.tw}aua': awe.: eit+:. wia:. �iwwm ....nu.,w..vu:..,:atM.:u:.. Hoorn. a.. �v,.:. �..,;..... w_.. v. u. �:. r: r.. l:. u._. �w:. .,;,,•..�,,...+r.r....,w4w•i.au n. J ` ,_,j -. r .'.._.gin',.— :c..�- ..._._.. _..,- ......'�..o. �. .: �,.:'..._.' r.:....: :•o:..�:.`�+::I.t,r.�::.:':a::r :r�.�:r DESCRIPTION OF SOILS ENCOMNITERED Iti TEST HOLES Lndicare level at «_Mich ?-ot,mdwater is encountered Indicate leve! at which mottling is observed I_�dicate I.e�el to r�rhicZ water le� el uses �-,er bein` eacountere�? - — Deer hole obsez Yations made by: DesiJ 'ProfZssiOnal Marne: Ad- dress: j i cn? t' '.r•' ftpoWT RD A& 4f Co tine vifla 13 ri �,v RD ...... . . . . . QV NW mv 4 ii VGST RD OLD -Rom.on YM ....... . . . . . . ....... ..... °'7 r v -01 c J f G P 1 h �R�fL� �o A14-,gft>i4 1Zcocp V,424,dEY -M 3 72. _ I —2--T M1 t3uQsou LAMA UmPIlS �e Y l214 4%,11&wkf IV`t itVi< 14%-413-144-1 TAM -� Ltl 4 °'7 r v -01 c J f G P 1 h �R�fL� �o A14-,gft>i4 1Zcocp V,424,dEY -M 3 72. _ I —2--T M1 t3uQsou LAMA UmPIlS �e Y l214 4%,11&wkf IV`t itVi< 14%-413-144-1 ill, DEPARTMENT OF HEALTH Division of Environmental Health Services T C UNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 - APPLICATION TO CONSTRUCT Aj WATER WELL } �LCA( A (- PCHD PERMIT 0A WELL LOCATION treet' Addre s Town Village City Tai� .Grid C�Gca� Cr " /ocl` Numb .. Lv / WELL OWNER ,,N amp- Mailing Address / /i /U6 Private - P G e FR / 511 1 /-d'S Ve, Zak �1 hd' �� //,y O Public USE OF WELL 1 -'primary 2'- .secondary KRESIDENTIAL ❑ PUBLIC SUPPLY Q AI /COND /HEAT PUMP O ABANDONED ' ® BUSINESS O FARM ❑ TEST /OBSERVATION p OTHER (specify .® INDUSTRIAL 13 INSTITUTIONAL ❑ STAND -BY. O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED Y /EST. OF DAILY USAGES ° " /" °gal REASON FOR DRILLING 13NEW SUPPLY WPFROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION []REPLACE EXISTING SUPPLY .O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING 7b bre , il u Af r` a/ 6 WELL TYPE DRILLED ®DRIVEN ODUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES �N0 IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: q Sec F 43 /0 ck e ST;. Lot No. / / 4 WATER WELL CONTRACTOR: .Naine,�lpry"a LI /7'n �ef-S IS..PUBLIC WATER SUPPLY( AVAILABLE TO SITE : YES NO p: NAME OF PUBLIC WATER.;SUPP.LX a�s7`r�ct TOWN /VIL /CITY 111141t:/,�i:'fl t-» UQ��+e � DISTANCE TO PROPERTY FROM NEAREST WATER MAIN ' Z/ " LOCATION -!SKETCH =x &> ".SOURCES' ..OF CONTAMINATION ._ , PROVIDED �ON REAR OF THIS APPLICATION OON SEEP ' ?'SHEET (date) (..ignature) 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. 2. 3. Oate of Date of Permit 2/87 Pump the well until the water is clear. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. Submit a Well Completion Report on a form Prov4od by the Putnam County Health Department. Issue: 19 Expiration: 19 ermit ssuing f icia is Non - Transferrable �� copy: Yellow Dopy: Pink Copy: H. D. File Building Inspector Owner Well Driller o-4 ULFAK I MtN I Ur HtAL I H : Division Of Environmental HgaA Services TWO COUNTY CENTER - CARMEL, N.Y. • 10512 (914) 225 -3641 WELL LOCATION 'CONSTRUCT' A ..WAT'w R` WELL'': WELL OWNER NAME. • AOORESS.- f/. FAusll i/' A0j_ 3' AYc- �ay� �slctcda�(�i� , /(� /��06 O 2USL C( USE OF WELL RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED 1 - primary WELL LOCATION SIRE0 AUORESS. 'IUWNI ILLAGEIGIY IAX Viu NUM6ER. �rdl� � / a.�� �e/6 xu. /0arn C 3 Go�j WELL OWNER NAME. • AOORESS.- f/. FAusll i/' A0j_ 3' AYc- �ay� �slctcda�(�i� , /(� /��06 O 2USL C( USE OF WELL RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED 1 - primary O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY MOUNT OF-USE YIELD SOUGHT — gpm : /NO. PEOPLE SERVED Z / EST. OF DAILY USAGE, ° -O gal. REASON FOR ❑ NEW SUPPLY %PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL �'°'r a'�( y��- rou.>7s Se=- WELL TYPE DRIVEN DRILLED PUG ❑ ❑ . D ❑ GRAVEL oTHE -A IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: k� S'e c F B 16C4 S-7 LOT NO.: // - / 7 WATER WELL CONTRACTOR: Name Norm om 4mC41 rs nj Address : pulha vr, I "/p 6 /Y V. e-� IS PUBLIC STATER SUPPLY AVAILABLE TO SITE: -9 ._ YES NO otiL NAME OF PUBLIC -WATER SUPPLY.- q 'ye, *,r544�G TOW11 /V /C DISTANCE T0. PROPERTY FROM NEAREST WATER.-MAIN tamd 5/0aes aw v .- LOCATION SKETCH_& SOUR „ OFTCONTAMINATION well aid ULL well K area. - .. t0 2& �� H 7s� ¢geld avid end -(date) � szp��L p� a (.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, h Date of Issue: ©� j 19 �G Permit Issuing 0 icial . Permit .- is . Non - Transferrable ' a' PUTNAM COUNTY HEALTH DEPARTMENT W�r,, DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons,'M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet 1 .of,. INSPECTION NAME ��%lil.Q� Orig. Routine' Orig. Complain ADDRESS r � Orig. Request No. Street unicipality:(T)(V)(C) Compliance i complaint Comp MAILING ADDRESS Final P.O..Box Post Office Zip Code Group Illness Construction TELEPHONE Reinspect'ion PERSON IN CHARGE _ ° Field,.Sampling.Only OR INTERVIEWED Field Conference Name and Title /l Other DATE (� (3 TYPE FACILITY j �.. TIME ARRIVED ( ?' • ) S1 TIME LEFT Explain FINDINGS: �• S INSPECTOR:. AI ignature and Title TELEPHONE :* PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this SIGNATURE: Field Activity Report .................. TITLE: