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Home My WebLink About4802DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.32 -1 -41 BOX 36 T wl Be , - I. I t L. , T-11 'ror lei , PvTNAM COUNTY HEALTH DEPARTMENT , Xt V � IN �75 DIVISION OF ENVIRONMENPAL HEALTH SERVICES PWP6SA:L 1ftR Siff TDISP(}SAI,''S OWNER'S NAME D�y. _ 5 PN a — 376 SITE LOCATION r e l- ni S i- Tt4# ` 3 /— y j MAILING ADDRESS L PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 612-6 14 7 TYPE FACILITY PROPOSED INSTALLER G-/t -4 6 'er AT PHONE 5�2 � '" a2 S`yJ " REGISTRATION # Of 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 i�lf to ca TreN Disapproved 'roposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. Date 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 camponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 61. 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. I, as own or reported agent of owner agree to the above conditions. SIGNATURE 1J r TITLE �� GATE o� W: Wdte (PCED); YeUcw (Tam HE); Pink (Applia mt) 1�ttIro ��Pa (� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �1 IoiPFLIC%!7'I'Oitl'O "CO�S'fRUCT _. please print or type CPC DPeP t #�� Well Location Street Address: Town/Village: Tax Map #y/,, !� ' A ke Pa2_ ka k._ 1, / M 6L hK Map Block Lot(s) Well Owner: Name: Address: Phone #: `' Q �± Lk Use of Well: Residential _Public Supply Air /cond /heat pump _Irrigation 1- Primary Business Farm Testimonitoring —Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield ught gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drillina New Supply (new dwelling) Iwf Deepen Existing Well Detailed Reason ` it E A c lv,e r for Drilling Well Type -- Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes No _ Is well located in a realty subdivisions Yes —No Name of subdivision Lot No. Water Well Contractor: a- rso,-, Address:_/ Is Public Water Supply available on site? ....................................... ................ .. ............. Yes _ No ✓ Name of Public Water Supply: Town/Village IDistance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. p IDate: Applicant Signature ) iLoyL.r 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 Departmel 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 Copnty. - A Date of Issue / —S Permit I Date of Expiration Title:_ Permit is Non -Trap ferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - OwneW, OrangVcopy - Well driller Form WP -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES please print or type PCHD PERMIT # AV-to Well Location: Street Addres : TownNillage A/ j Tax Grid # Map Block Lot(s). Well Owner: Name: C(A Address: �04 �� y i 0 C— � P k �1 Well Type: V Drilled Driven Dug Gravel Other Depth Data: Well Depth 8®ft Static Water Level ft Date Measured (v 0� Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Contractor: Name: Address:. (' (62— AF0 �� S�F ��Aao\ V A 1 V (-tN\C k 1• Dn —� A1, Reason For Abandonment: , A e� MNN L -t �4tr s� l - rgll� 0� � � Description of Work To Be Performed: I I� ® Signature: Date: i Cl App scant PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York, State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineate on the application for this permit has been completed. J Date of Issue Permit Issuing Ofdci Ti White copy: HD file; Yellow copy - Building Inspector; Pin&opy - Owner; Orange copy - Well driller Form WA -97 OF PUTNAM (COUNTY DEPARTMENT ®I' HEALTH AP PILICA ll7[4` N I'O'A1(1;ANWGN X *tA k 1[� `° II �. �LI[,�" please print or type PCHD PERMIT # "V Well Location: Street Address: Town illage Tax Grid # &k /` Map Block Lot(s) Well Owner: Name: le)e Address: W I Type: tDrilled Driven Dug Gravel Other Depth Data: Well Depth 1 �D ft Static Water Level ft Date Measured 1 � v /v � Use of Well: "Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Contractor: Name: Address: /�v hti� n d 1 S y r Vii' �-� �, a U oil 1 A3 Reason For Abandonment: )k ��.�d -fie f�.��r -� �; -��^/ - R comas o��-E� z-,Z Description of Work To Be Performed: Date: Applicant Signature: PEIf8MffT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well.driller Form WA -97 13.00 1 000- 000 0 -70 V 9 0 6 1 5 .--tx / 51/ Al ry