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HomeMy WebLinkAbout4180DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.75 -1 -36 BOX 32 a PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICI AL USE ONLY A!) SITE LOCATION M 0 r r i� S e y D ( � TM# 9�. 7E- 1- �6 OWNER'S NAME PHONE q) q ` V /7 ? - t MAILING ADDRESS AU4, r A A1470. P 9 v PERSON INTERVIEWED t' / ,J,-), PCHD Complaint # ame & Relationship (i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER _:I p PHONE —I ADDRESS REGISTRATION# `` 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, & " orted a rit of wrier agree to'the conditions stated on this`form. M _ SIGNATURE TITLE_ L/ �Nf.N DATE 0 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 (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. Proposal approved Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML e2 Z DATE SITE LOCATION OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DBPARTMF.NT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'I 01A 0 PERSON INTERVIEWED t Y tie , SSErte �!, PCHD Complaint # i7ame Wons7�p (Le., owner, an dic j' DATE TYPE FACILTTTY PROPOSED INSTALLER T" D PHONE --- ADDRESS REGISTRATION# G proposal {melude 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. 1. 7fo 6,4L S �rr•c Td�< . I, as owner, or r rt f owner agree to the conditions stated on this form. q/24/� SIGNAnXE DATE k%'- Pro ul ap9m ed with the fojWAng wadi 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.,125© °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. Proposal approved Inspector's Signature d: Title COPIES: White (PCHD); Yellow (Town B% Pints (appli=) PC41P 99ML ..•a t� C N to der qs TA4-D -449 fJ . �. rlr fid r r {l a+ fax 17nd 1 2h t� DUAL Ag Manufackured nfij Tjv �C3 . :M ra t: Ma -W, a d wa -& T1.I = To o i►��� i-�'a'd f'+ t�►ti Tea fOCA .,.... ""Par-ane /J use 14-20 r DUAL INFILTRATOR Q'�ETA.11=� ©0•�i Ar• , .. i s l N N CD c 0 a I Kt vz Vzx UA Or lu vh c•.4 X - DuAl ti lu V-1 lie A M e, �- 2.0 Type 3.4'WL ,4r* Diz. Oullat Too View 8•11 Core 21 3' W649 twid Loyal Side View MA,4tjo,tx-- TZ> ea*ww—: Carr 2% no CQ:Y 12 +I0' co"I _j 4 T--T- co D 0. pole &ORRIS.S, DRIVE A.X.A. 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T I HAW--y.> PAS.4 f C1 A-/, TP S Co-7 ef el -TF T P4 Fr 15101 L -Tb 7 �- �, j, . (. 4. P- r PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAYR SITE LOCATION Vk4ZtZ1 SSL DIZ. TM# OWNER'S NAME ea C. MAILING ADDRESS / %_ e OFFICIAL USE ONLY -1-36- . E 414 9'46 — PERSON INTERVIEWED i rJ '_._.- PCHD Complaint # Name F- Relationship Le., owner, to ant, etc. DATE TYPE FACILITY, PROPOSED INSTALLER T 5 .D PHONE ADDRESS REGISTRATION# 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. �. 7t-0 6 A L SIc- 7 -4 K . �l C I, as owner, or r rted g nt f owner agree to the conditions stated'on.this form. SIGNATURE TITLE 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 o /z7 �s DATE---- 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. Proposal approved /4, Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML ATE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AP$I.ICATION TO CONTRTI,C_'T-:4: ,WATER .WELL_ please print or type PCHD Permit # 1�G% c✓e{ �%� Well Location: Street Address: Town/Villa e Tax Grid # otz4 SSc D7 _ C � Map j Block Lots x. Well Owner: Name: /� ,�? Address: Cleo C40. 6P Y✓14rAl, 4e, La An h� Use of Well: Residential Public Supply Air /Cond/H at Pump Irrigat on 1- primary usiness Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling LIew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type LAZDrilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No L,- Is well located in a realty subdivision? ............................................................. :....... Yes No t✓ Name of subdivision ' .— Lot No. Water Well Contractor: is P. Address: Is Public Water Supply available to site? .................................. ............................... Yes No 8✓ Name of Public Water Supply: Town/Village ^- Distance to property from nearest water main: �- Proposed well location & sources of contamination to b rovided nseparate sheet/plan. -�8L..b — pplicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue �� vim' -o y Permit Date of Expiration/ Title: _ Permit is Non- Transferr g e White copy - HD file; Yellow copy - Building Inspector; Pink - Owner; Orange copy - Well driller Fnrm WP -97