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HomeMy WebLinkAbout4123DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.73 -2 -42 BOX 31 04123 �' � tiL Z'' 16 F♦ ., , W III 1 J I♦ .r , 16 I 'TJ 04123 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 # ,vr /os?9 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 � -sty, I I N s y �a0 6 ,4L - IAW a r' I �t J 0 -� edin h 1 �., �cU SP(( ca ^0. 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