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04709
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04709
OWNER'S NAME I JL
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED
PUn M OOUNI'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENEAL HEALTH SERVICES
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
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PHONE
Pal) Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
Va—ro PHONE
REGISTRATION # X1--3
Pro (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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Proposal approved
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Proposal Disapproved
with the following conditions:
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Date
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 ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
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Owen Sullivan
Route 9D
Beverly Warren Road
Garrison, Nd 10524
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Geneva Road, Brewster, New York 10509
(914) 278 -6130
Re: Well permit
JOHN KARELL Jr., P.E., M.S.
Public Health Director
June 8, 1992
Dear Mr. Sullivan:
As per your request please find enclosed an application to construct a water
well.
If I can be of further assistance please contact me at ext. 161.
Very truly yours,
&h' (/Y & W,
Robert Morris
Assistant Public Health Engineer
RM /Jp
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 p
PCHD PERMIT $ �/
WELL LOCATION
Street Address Town/Village/City Tax
o
Grid Number
9/.�S = - 39
WELL OWNER
Name Mailing Address
Q, / U
rivate
11 Public
USE OF WELL
CV- primary
2- secondary
KRESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY
p ABANDONED
(3 OTHER (specify,
p
AMOUNT OF USE
YIELD SOUGHT - y¢ gpm /# PEOPLE SERVEI?___+ - /EST . OF DAILY USAGE+ gal
REASON FOR
DRILLING
90PLACE EXISTING SUPPLY 0 TEST/ OBSERVATION.' G ADDITIONAL SUPPLY
❑ NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
'DRILLING
WELL TYPE
DRILLED
DRIVEN
QDUG
OGRAVEL.
�OTHE�t
IS WELL SITE SUBJECT-TO FLOODING? YES. ✓ NO
_...._.•:$• :$^ S'LCTED A ON L . S .
Lot No.
WATER WELL CONTRACTOR: Name AA ",kS 10,(J Address: 101 tea¢ IA/�l ,AY'
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO tjppy F_
NAME OF PUBLIC WATER SUPPLY: /. TOWN /VIL /CITY,
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
gON SEPARATE SHEET .
(dat) ('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
thirt7. (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 operatioris,.the applicant shall take appropriate action to assure that
any and all water or waste products from such well dril ng operations be contained on this
property and in such a manner as not to degrade or o er ise cont am nate surface or groundwater.
Date of Issue: 3 19 ot! �� q
.1° 1C".'-t :�4.6T�• -;' — _ — '°'°:_ . .1:. �1' .. � ti .i '.s`7�!:+�`4�: � r':`..LZ:`: "�".'�i. -'.i: "'_.'dam.`. '."'° 4
15afe' 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