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HomeMy WebLinkAbout4691DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.24 -1 -30 BOX 35 I, -- M r ' f �� ' E ;I 1 kQ IN 'L ,.�i, r or �t ' , IIr I 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 ■ _.... __ J ... 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 h al r , ■ � ._ a � � _. i, _ ✓ ■ ■ .. y ■ ■ � -� - - __ �� �� ��� �, � i II t� I �' i i I �:,� , � � ■ �■ ■ v ■ ■ ■ • ■ ■ � ■ ®■.� ■ ■ ®.�� ■ ■ ■■ ■ ■■■ �. ��■ h al r , p eow, V-e ro 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 r