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SITE LOCATION_
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
H
MAILING ADDRESS
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T-a PHONE 9W - -�-21f-6DI6Z
PERSON INTERVIEWED PCHD Complaint #,
i A Name & RelationshiD i.e.. owner. tenant. etc.
DATE l
TYPE FACILITYS
PROPOSED INSTAL ER t f9-P-O (7M(e f2'%' PHONE . �,�-p1.s`1S-
c�i�- �p
ADDRESS �. r _REGISTRATION# r G I
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.
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_I, a Qwxl r .pr eported_agent of,
�wner.agree- to -fne
SIGNATURE Tl
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*, t f t_ D 4 & $ .Jq ..
`i'�ck o p4 s 0 114Lt.7 T-o c. C. Q tv
ns- stated on -this form. - --
DATE—
Proposal 2
approved with the following, conditions ,/ �,�,' Gr'1 yT rt:�i� 7� /5
1 Procurement of any Town permit, if applicable. Q
Submission of as built repair sketch in duplicate showing:
a. Owner's name C4-t c- PC oo -- sr roz' rA-ciGT a yam%' <<
b. Site Street Name, Town and Tax Map number. r FZ7iQ'At rats
C. Location of installed components tied to two fixed points (e.g.,' a co a s)�
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 ormed in accordance with the above proposal and conditions.
Proposal approv%,
ej-,, � _
pector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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05/08/2014 09:02 8452258420 BOVDARTESIANWELLC PAGE 02/06
r PUTNAM COUNTY DEPARTMENT OF HEALTH
DIViSION OF ENVIRONMENTAL HEALTH SERVICES
WFI_L CdMpl.PTION RI±PORT
Well Location
Street Address:
Town /Village :,
Tax Map
Map Block Lot (s)
Well Owner:
ame; Address:
Use of Well:
1- Primary
2- Secondary
Public Public Supply ._ Air coed /heat pump _Irrigation
Business Farm - Test /monitoring . _,,,•Other(specify)
industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion XCompressed air percussion Other(speclfy)
Well Type
_Screened Open end casing Open. hole In -bedrock Other
Casing Details
Total Length r 44 ft.
Length below gradet.
Diameter /np -in.
Weight per foot ; !b/ft
Materials: X Steel Plastic Other
Joints: Welded X Threaded Other
Seal: Cement grout Santonite Other
Drive shoe: as _ No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
I Len th ft
Dept to Screen ft
Developed?
First
_Yes —No
Hours
second
Well Yield Test
Bailed _Pumpad Compressed Air
Hours
Yleid gpm
Depth Date
Measure 17m land su wt flee -at c Spot )
Puting yield test t) 1011opth Of CorapiftlAd wall In ft
IP more detailed
information
dcscriptions or
sieve analyses
are available,
please attach,
Water Searin
in
Formation Description
ft,
ft.
Lend Surface
a 72a
M6 I-Ar
If yield was tested
at different depths
during drilling
list:
Feet
Gallons
Par Minute
Pump /Storage Tank information
72r-
Pump Type — _.. Capacity
i]epth Model
Voltage ._ -_.. HP
Tank Type Volume
ft ,..
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NOTE: Exact Location Of Well With diatadCe3 to 8t least two permanem LanumantE to ve ProvLVea ❑n a ReparL1te 51 Lut3uptan,
White copy. HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Weil driller
Form WC -97
nom.. wrnw
LCoG /067
PUTNAM COUNTY DEPARTMENT OF HEALTH
�- DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO C® IS (21JC1fA 1AlAT tR TELL -�
please print or type NCR D'PeeeIt�+�
Well Location Street Address: Town/Village: Tax Map #
r Block
/Lim Ma Lot(s)
Well Owner:
Name: Address:
P n
A�o��
/
Use of Well:
_Residential _Public Supply Air /coed /heat pump'_Irrigation .
I- Primary
Business Farm Test/monitoring —Other(specify)
2- Secondary
Industrial Institutional Standby .
Amount of Use
Yield Sought gpm # People Served Est. of Daily usage gal.
_ Replace Existing Supply lest/Observation Additional Supply
Reason for Drillin
.New Supply (new dwelling) Deepen Existing Well
Detailed Reason
®�
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _ No-y—
Is well located in a realty subdivision? ........................................... ............................... Yes —No,
Name of subdivision_ Lot No.
Water Well Contractor: _ Address �/1 Z4 <gZg �j�/
1
Is Public Water Supply available on site? ....................................... ............................... Yes _ No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date:_. �/< :: Applicant 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 Deoartmei
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 Commissioner of Health. 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 Permit s uing fficial: ��-
D ate -of Expiration - Title: �� /,`C�?AI T-90
Permit is Non - Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -g7
Rev. 3106
A NGWA
CER-rIFIEO
F11
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Bob Artesian Well Co.,-,Inc.
1054 Rte. 52
Carmel, N.Y. 10512
(845) 225-3196
Fax (845) 225-8420
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