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BOX 35
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04691
N COUNTY HEALTH DEPARTMENT
PUT AM COU
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
r"r1VrVr7ML. F%Jn OG►►/1�G 1 f7GM 1 1►11.1. 1 V 1 v 1 5-n§ 113-■ �S ■
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YE NO Internal Use Only PERMIT M
❑ Repair Permit issued in last 5 years" ❑ ,Not in Watershed
❑ f Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑/ Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
DATE P I
PROPOSED IN TAL
ADDRESS � (hAl
27SU��an TOWN
, tenant, contractor)'
FACILITY TYPE
' TM# .11,Ra - -I" 30
PHONE #
PCHD COMPLAINT #
_PHONE # QI47Sl�i
STRATION /LICENSE # 11b7
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair. _ _ t % 1- 1, _
I, as owner,agree
SIGNATURE ;
(owner)
I, the, septic installer,
this form
TITLE A0AJeVLvrV.K DATE / I3
with the conditions . of this.permit for the septic system.repair
SIGNATURE m6itz TITLE ,%2,S . DATE
(installer)
Proposal aooroved with the following conditions:
1. Procurement of -any Town Permit, if applicable.
2: Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
6. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
// r
Ins ector's Signature & Title D t� e EApirationfDate
,Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Putnam County (Department of Health
)[Division of Environmental Health Services
SSTS Repair — Final Site Inspection !
Date: � I �/ XS Inspected b � /Z Installer: �C
gtmWt cation: ,: � SyrAr". Owner: i /n No L/v
Town: Repair Permit GtiG/ —/ ! TM #. �s -
- . , f ----
Additional Comments:
Rftff Rev -011312
viii. Ends capped..
-
u.°
a. 95`t3:Ai+ealocatedas er roved lans
b. Fill ebction-
c. Distance from water course/wedands
4. ®veNlli Workmaul i
a. Boxes properly grouted and installed correctly ...........
b. AD pipes flush with inside of box .........................
c. Rackfill material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
Rftff Rev -011312
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
- AP.P���'AT�O�� '�0, CQNS�'�L ?�T.. A.. F�TAT!ER::�i!FEI:,L -� :.�::� ...:t:. :� • •�j.�,SJ�,�
'PCHD PERMIT
WELL LOCAT ION
Street Addre s
P7 S r1A Z
Town Village City Tax Grid Number
IA 4e �e'd'& e, d -! - 0,2(o(- 00 QO
WELL OWNER
Name
ti/ tQ4&
Mailing Address
A1-) A+' G r 'offtS EGG
¢Private
0Public
E OF WELL
primary
2- secondary
RESIDENTIAL
9BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
b INSTITUTIONAL O STAND -BY
D ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /46 PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY WDEEPEN EST /OBSERVATION 13. ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING EXI STING WELL
DETAILED
REASON FOR
DRILLING
"
WELL TYPE
DRILLED
13DRIVEN
[]DUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES r NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name /AI N a V7 SR/L/ 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:....—
_..:.._.�.._ -.. rte_. �._�.�:., - ...� � _ ;� -� .,,. •.�.-
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
11-If 3 ❑ ON SEPARATE SHEET r-77�`
(date) igna ur
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 drilling operations be contained on this
property and in such a manner as not to d grade or otherwise contami ale-- u �'groundwater.
Date of Issue: ��� fi' —19
Date of Expiration 19 Issuing Official /
Permit is Non - Transferrable White copy: HD File Pink copy: 0 r
3/89 Yellow copy: Bldg. Insp. Orange c�p Well Driller
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