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BOX 31
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SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION.OF ENVIRONMENTAL HEALTH SERVICES c a n
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PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
v
10 Internal Use Only PERMIT #�T�`w u
epair Permit issued in last 5 years Ot In Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
OWNER'S NAME
MAILING ADDRESS
APPLICANT
`12V TOWN
e1,*,�z Ly 7, ' .
2/1
TM #97e72.
PHONE # J'2__4-2_C.0,%
Name & Relationship (i.e., owner, tenan t
DATE ZZ M /� FACILITY TYPE PCHD COMPLAINT # fief'
PROPOSED INSTALLER �� �_ �.., r PHONE # 9ys j�25a& 2Y
ADDRESS 2 �,� //ps� -�.- ,wG.- /2/% REGISTRATION /LICENSE # Aol7
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. /
.0< ,E A/S 3o Y® �"S y` i4
I, as owner,agree to the conditions stated on this for
.�" L
SIGNATURE ?e TITLE -0o-r, DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITL DATE
(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
Proposal Approved Proposal Denied ❑
In pector's Signature & Title natLd Ex ration Mte
,Repair proposal is in compliance with applicable codes Yes No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
ARROW EXCAVATING, INC.
15 AVALON COURT
HOPEWELL JCT., NY 12533
(845) 227.4505 (914) 528 -4395
JOB /� /O�� �• �CT I .'. 2l
SHEET NO IA11-4 1%d -,; ICV OF__/
CALCULATED BY�� 17&'Z 4d/ DATE _i?-Z V-Z0 4
CHECKED BY
DATE
I
I
MARVIN O'DELL
Inspector.
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
Robert Morris .
Dept. of Env. Health
110 Old Route 6
Carmel, N.Y. 10512
July 22, 1987
TOWN HALL
'PUTNAM'gJ'ALI. @Y;
(914) 526 2377
Re: Proposed Well - Pleasant Road
Monte - Lake Peekskill, N.Y.
Dear Mr.' Morris:
The.proposed well shown on sketch drawing submitted conforms
to the requirements of separation between any SSD system and,
therefore, would be approved by this Department for construction.
Upon completion, a copy of well drillers'log and water analysis
report shall be submitted to the Building Department by the
owner before the well is put in service.
Very truly yours,
Ix
t%
MARVIN O'DELL
Building Inspector
MO'D:es
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy . Commissioner of Health FIELD ACTIVITY REPORT - Sheet of
INSPECTION
MmE ... Orig. Routine
Orig. Complain
ADDRESS I EA So/yvi iaj- (�Jf- (jail ow Orig. Request
No. Street Town No. Campliance
Complaint Comp
MAILING ADDRESS Final
P.O. Box, Post Office Zip Code Group.Illness
Construction
TELEPHONE
Reinspection
PERSON IN CHARGE Field, Sampling Only
OR INTERVIEWED Field Conference
Name and Title
Other
DATE TYPE FACILITY Vi
TIME ARRIVED d7o TIME LEFT 0-4-3 Explain
FINDINGS t.
bignar-ure ana
tle
PERSON IN CHARGE OR INTERVIEWED
I acknowledge this Field Activity Report. SIGNATURE:
a
TITLE:
DEPARTMENT OF HEALTH
Division of.Environmental Health Services
WO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
_..:.:. rx. ..a. •.r.wr.+c: •:•.. .. .. -__: .. ......_._.._.. ... '
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # J
WELL .LOCATION
Street Mdress Town V3, lage City Tax
A�"41r A5 "I l
G id Number
WELL OWNER
Name
^^Mailing Address rivate
Y �� i8® A� Al. Y, I�`'� ❑ Public
USE OF WELL
1 --primary
2.- 'secondary
RESIDENTIAL
BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
0 FARM ❑ TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
C ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
fiMEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY
fOREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
OTEST OBSERVATION
DETAILED
REASON FOR
DRILLING
p y)at 4 NC7
�
y ems% G
WELL TYPE
0DRILLED
DDRIVEN
E]DUG
DGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION;/
Lot No.
WATER WELL CONTRACTOR: Name /V. 4-,+ymFmo -- l Address: ?kn /LL
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES NO
NAME OF PUBLIC WATER SUPPLY: N� S • TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: 7C'7�SpIt/fJL G�%�"� 1.�.'✓►v.�0•+�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION r ON TE
dat) (signat re)
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 Ted by the Putnam County
Health Department.
Date of Issue: 9-14 19
Date of Expiration: 9, (q 19 541 Permit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
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