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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR : k
YES NO Internal Use Only R Q
❑ ❑ Repair Permit issued in last 5 years ❑ Not..in Watershed
El
SITE LOCATION
OWNER'S NAME
❑ Repair within Boyd's Comers, W.. Branch or Croton Falls Res. ❑ Delegated
MAILING ADDRESS
APPLICANT
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
Cal
V6 1 / TM # 0 ' I�
C S PHONE #/s
2. V A-2L 10,5'71
l`� 1 r►� h r �s� eve en �S�
Name & Relationship (i.e., owner, tenant, contractor)
DATE �/ p FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER yon, ve.y, � .PHONE #
"Q . S /Y— 7-ss -��S�-
ADDRESS �3�/�„ ,�� �G►t�ar� yy / /�y REGISTRATION /LICENSE #
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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 trenches)
.NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or reported agent of owner agree to the conditions stated.on this form
a�•
SIGNA'1'LJRE TITLE OWA)e2.
.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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditi ons
P oposaoAp ov ed Proposal Denied
spector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
DATE 11710 7
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
`APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # _
WELL LOCATION
Street ddre
'�
s Town i
ge ty Tax Grid Number
;VU
WELL OWNER
Name
Tlpk�lpjop/ Lx
. ailing Address
4-5 P
_
rivate
O Public
USE OF WELL
I primary
2 - :secondary
KRESIDENITIAL
0 BUSINESS '
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
U INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify
O.
AMOUNT .OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED /EST. OF DAILY USAGE__ gal
REASON FOR
.DRILLING
O REPLACE" EXISTING SUPPLY 0 "TEST /OBSERVATION 'Gl ADDITIONAL SUPPLY '
O.NEW SUPPLY (NEW-DWELLING DEEPEN :E ISTING WELL
DETAILED
REASON FOR
DRILLING
70 a/a a 717 7 j
ey
WELL TYPE
DRILLED
DRIVEN
;QDUG
aGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
D 'I.^rTANCI: TO PROP RT72 RO:7i NZ—A&Z ,ST WATER MAIN: _.. ._ .
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED.
% 1/f /DON SEPARATE SHEET
(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
thirti� (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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue; 19 -- -J-- ���
Date of Expirat on 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
4