Loading...
HomeMy WebLinkAbout4168DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.75 -1 -2 BOX 32 y ' I , �L Li i r J ■ L iT� Is 0 r.��' r L t- 4 me or 1 k.11i I' j June 21, 2004 12:52 PM From: Precision Excavating Inc. Fax #: (845) 736 -0571 Page 2 of 3 9 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM R 2AI OFFICIAL USE ONLY t,2 -11-0 SITE LOCATION M VANdAW OWNER'S NAME f3,11 �no� ��, ...PHONE — so MAILING ADDRESS 45 tJsc na l a1r� `i 1. P r,arr, U,�+U�.I . AIW lInsiq PERSON INTERVIEWED PCHD Complaint # acne K Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLERP;Sicoc-, CC -xr^,2AAI cQ ?s-`. PHONE CR45) -7 36— QSZ ADDRESS_3���� (�ar�, sor,_ 1l `REGISTRATION# �r- Proposal (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 from licensed professional_ engineer or registered architect. I, as owner, or rted age of ownF agree to the conditions stated on this form. S IliA7ATilItE" T'17`I:EA ►i ! eC'� DATE" y' Proposal v f o 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 munber. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6 deep C. Installers' name and :,nwnber. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title ATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC-RP 99N L LK: ai is t. 1 ;j V Homeowner: Bill Breidenbach 45 Oscawana Lake Road Putnam.Valley, W 10579 (845) 528-9650 Town of Putnam Valley Tax Map Number: 83.75-1-2 Dewription of Repair to Syst4l: Existing Tank , . Iseptic Installation of 120' of 2' Wide Trench With 1 Y2- Washed Sto& Installer. Philip Leonforte, Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736-0571 (! : i—JV RQ.11-01 --IK,.1 0 . ....... .... 23-.;21 41M MR i�z _h" mv MV U) :. p 01� ............. M. v,l UNF 4 FLOOR �ik 6 E, g�Ml j H E UNDF-.R N N RON,- V., Homeowner: Coric Bill Breidenbach '0-8 45 0scawana Lake Road. Ira ibdK 11RE T * Putnam Valley, NY '10579 r (845) 528-9650 T .0 b-ofyutnam Val k y Tax Map Number: 83'.75-4,-2 13 Description of Repair to System Existing Tank Installation of 115' of 2'. Wide Sel 'Trench With I Y2" Washed Stone Installer: Philip Leonforte Precision Excavating Inc. 3 Rochambeau Road A Ti Garrison, NY 10524 (845) 736 -0571 �6 W 70,301 ire "we - ----- . ....... a al too N <C CT- b^ KA RQ.11-01 --IK,.1 0 . ....... .... 23-.;21 41M MR i�z _h" mv MV U) :. p 01� ............. M. v,l UNF 4 FLOOR �ik 6 E, g�Ml j H E UNDF-.R N N RON,- V., Homeowner: Coric Bill Breidenbach '0-8 45 0scawana Lake Road. Ira ibdK 11RE T * Putnam Valley, NY '10579 r (845) 528-9650 T .0 b-ofyutnam Val k y Tax Map Number: 83'.75-4,-2 13 Description of Repair to System Existing Tank Installation of 115' of 2'. Wide Sel 'Trench With I Y2" Washed Stone Installer: Philip Leonforte Precision Excavating Inc. 3 Rochambeau Road A Ti Garrison, NY 10524 (845) 736 -0571 �6 W 70,301 ire "we - ----- . ....... SITE LOCATION-46 OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT XVISION OF ENVIRONMENTAL HEALTH SERVICES t v ..p •.. •. -+Ta. ,�a'[,rg.... ems.. �.. a.-v ..�.. m.- .,p ..... r. �. _:� -.� ♦ r.. r.. . OFFICIAL USE ONLY CIO-/ ® ` 3 . ']6-- / PHONE SCE PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER G =,2i i —AJ nn_ �C. PHONE ('_Q�►S) ADDRESS 3nc (wasvr,.1t4 REGISTRATION# 105 4 Proposal (include sketch locating all adjacent `yells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. i; as �iWner -br of ie07a of owner agree to `the conuitions-stat4ed uri �f SIGNATURE TITLE :J :edc: Le tec— DATE f o::: 1 --C- Proposal approved with the follo 'ng; 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 comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposalapproved� Inspector's Signature & Title COPIES: White (PC) ID); Yellow (Town BI); Pink (applicant) PC -RP 99M L DATE r i �• is S s. i< tl' a. r i gL 1 , Hom Bill Br 45 Osc eowner• . eidenbach awana Lake Road Putnam Valley, NY 10579 (845) 528 -9650 Town of Putnam Valley Tax Map Number: 83.75 -1 -2 Description of Repair to System: Existing Tank Installation of 120' of 2' Wide Septic Trench With 1' /Z" Washed Stone Instal ler: Philip Leonforte Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736 -0571 'a 4: ,r t� �b d' �t e' v� 'u. • i i 1 4. Y• DEPARTMENT OF HEALTH keA C w A L Division of Environmental Health Services DT 4 Geneva Road, Brewster, New.York 10509. F C-2m- (914) 278 -6130 U A'F�L;3CAZICST"TO Ct7N57'FtUCZ A� WATEV �T�,LI: T 171 L.c PCHD PERMIT # WELL LOCATION Street Address Town/Village/City Tax-Grid Number .. W A fV N A LK'- 20 A Q P672, VALLPW loe - - WELL OWNER Name Mailing Address 5U2 EVA _ `3 _S J , e �� tx�3 D Public E OF WELL 1 primary - secondary � RESIDENTIAL O PUBLIC SUPPLY O BUSINESS O FARM ® INDUSTRIAL U INSTITUTIONAL ❑ AIR /COND /HEAT PUMP O ABANDONED O TEST /OBSERVATION ❑ OTHER (specify O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVEDJ'S /EST. OF DAILY USAG C Z> al QWREPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION GIADDITIONAL SUPPLY ❑ NEW SPLY NE DWELLING 13 DEEPEN EXISTING WELL X l U , G5�0 REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ODRILaD ® DRIVEN ®DUG ® GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES Address: NAME OF PUBLIC WATER SUPPLY: N A TOWN /VIL /CITY D.ISTAAiCE ..T..:PRG`PERT7�FROM` �TE�SREST. WATER x„ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVI ED ®ON SEPARATE SHEET -- (date) (si to e) 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 thirt -y (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 of e w se contaminate surface or groundwater. Date of Issue: 19 / �� Date of Expiration 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 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 Prwn DFRMTT 1 WwW40-sa WELL LOCATION Street Address Town Village City Tax Gricyu ber WELL OWNER Name -� M iling Address <� C-..- ® Wrivate D Public USE OF WELL - primary 2 - secondary 13.:�MSIDENTIAL O BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION CIINSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, Q AMOUNT OF USE YIELD SOUGHT �gpm /# PEOPLE SERVED -5--5—/EST. OF DAILY USAGE ! Sal 'REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY ❑ NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING Z � WELL TYPE DRILLED DRIVEN ODUG OGRAVEL aOTHER 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 - - DISTANCE TO -PROPERTY FROM NEAREST- WATER 'MAIN:-**"-- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED rte% OON 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 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 drill g operations be contained on this property and in such a manner as not to degrade or of w se conta inate surface or groundwater. Date of Issue • 61-3 19 r /� g Date of Expiration 19�v $ rmit Issuing Official �`° /x Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller & t � flf- oo� rP ji cl V-5 C-1 - WV iL ..........