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HomeMy WebLinkAbout4814DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.33 -1 -33 BOX 36 ' ii -, iii' r �, am ■ �, 1 , PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR "DES T " . Internal Use Only PERMIT # 1' ❑ Repair Permit issued in last 5 years ❑ of in Watershed ❑ 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 j �u� r��5; aP O",TOWN � e k -�� �' TM # --' -� OWNER'S NA MAILING ADC APPLICANT DATE "7 - 1 `1 -p5 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER ��ec -; `�; ,�,-� xca �ak� �� PHONE # ADDRESS 3 f��. e am - kRA Gzar( iSoryREGI.STRATJON. /LICENSE.. #__._.._{".� _ f 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) f pr ,,P�Tfro censed professional depending on the nature and extent of the repair. 3 /`, �� °i� �� � L- ► - _ ` � QT]a �•R! 7Tii _ :TV � C -�'] / /�' lam% �/:� Ii�� - Y 0 I; as owner,agree to the conditions stated on this form ; SIGNATURE TITLE O W ?qC r DATE 7" i 71 ` d q (owner) I; the septic installer, e t ply ditions of this. permit for the septic, system repair ~ SIGNATUR TITLE DATE % D (installer) Proposal approved 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 b. 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 ❑ 3 © o Ins ector's Signature & Title Dat6 Expfrafi6n. Date Repair proposal is in compliance with applicable codes Yes 0 Nook COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 i y� n1 .,% / A Homeowner. Philip and Wendy Decanio 7 Sunnyside Place. Lake Peekskill, NY 10537 Town of Putnam Valley Tax Map Number: 91.33 -1 -33 Description of Repair to System: Installation of 30' of Infiltrators With 1 %2" Washed Stone for Fields Installer: Philip Leonforte (License #1022) Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736 -0571 I PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAiF ,t VES Id Internal Use Only PERMIT # - /4:� T4 u u Repair Permit issued in last 5 years ❑ in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ L Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION un TOWN TM # OWNER'S NAME I; �aCc� r�; PHONE # MAILING ADDRESS `"7 ` , f, Q..`�o trJl a \ �lre .Q �:� 11 n x7 t,- ,c-.2 -, APPLICANT Name & Relationship (i.e., owner, teha t, contractor) DATE "]- j "j -09 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER ��., �;,,,� �c�a���}, PHONE # ADDRESS 3 �� }r> .,, ,� �;, RA Garr ;san REGISTRATION /LICENSE # 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 oroP9sal from f icensed professional depending on the I, as owner,agree to the conditions stated on this form SIGNATURE �, _ TITLE D W ?fie ,j- DATE 7 (owner) I,,.the septic instailer,.a. e t mply wit ., c ditions of this permit for the septic - system repair SIGNATUR . .. TITLE S r, ' ; ?/ DATE % %7 Of . -(installer) Proposal approved 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 b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) A. Installers' name and phone number I 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 F] A�6� -t-2. dEe�0,1 -9/3 /Z 3 p Inspector's Signature & Tille 7 D to Exp' atio Date ,Repair proposal is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 c Ir 10 KRAA4ERS N \ PUi Ail WLEY ............... .......... ............ I'll sl s7i RD W w 0 >i Nlr .053 -m 1 3r m -v 20 A 4$1 . offl , 11 1.0 g.A zz m wi MR R SLA wtv C�ld A I p 4 OCo 6wp 4Q� $1 4Vf w SKY LA — 'T A, I t Foll DR i W, lu. 7 GO oll 1 '71 K LA( CO Q1 [nam. FINCH 01 VALLEY'@ 0 CT ms I _ DIN -/ iome Itavid 151 o' lit, i co Sheet L_ _of --�— PUTNAM COUNTY DEPARTMENT ,OF HEALTH j s.. DIVISION OF ENVIRO:NMENT-AL H- E -AXL-H SERVICES— FIELD ACTIVITY REPORT N A'TAF • d Tel: . AT)T)RFSS' Street Town State Zip i . PERSON IN CHARGE nR TNTFRVTFW .T): �S�c�(� Tate: ` Z�z /10 Name and Title TYPE OF FACILITY :f.0 FINDINGS:- T Signature and. Title RFPC)RT RF F.TVFT) RY: I acknowledge receipt of this. report: SIGNATURE; 02/96 Title: c C/ ear I i T Signature and. Title RFPC)RT RF F.TVFT) RY: I acknowledge receipt of this. report: SIGNATURE; 02/96 Title: SITE LOCATION i 0 WNER' S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM RIEPAR Acc TM# WGM OFFICIAL USE ONLY -d �_ffm PERSON INTERVIEWED ? k t L 92 ,J�C�4 �1 t0 PCHD Complaint # / dame a ations ip ki.e., owner, tenant, etc. / � DATE G -7 Io ( TYPE FACILITY PROPOSED INSTALLERI - k1Z I ii o 'R 6� e.+ PHONE _2y1 �' 9� - ADDRESS 33 �� 1 n4 r°J r� r,;j,� - (a5) REGISTRATION# P� Proposal (include sketch ocating aIlfl adjacent v✓clIls)e 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,-as -o li; -ox reported age;it of owner agree to the conditions stated'on thisIorm.. SIGNA TrME ✓L-�-� Pro,12osal appmved with the folhing conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name DATE b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). 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 performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title X16ATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DEPARTMENT OF HEALTH SeC 1� Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225-3641 P P LY CATION ' T &1 T' RUC"I` 1 tA iie;Wifft ; . _ : > tea •.... K . _ _ . , /. " - r. PCHD PERMIT 41�.1I l �i WELL LOCATION Stree Address Town/Villa g "e City Tax K �n s 4- o'. K I'I Ji 1�e l�s Kf J Grid Number L OWNER 2 e f S5� S' Mailing Address �- i�c -.�e r5 1Y. /'o >o ! pPrivate OPublic SE ; OF 'WELL, 1 - 'primary 2 - secondary' CKESIDENTIAL ,O. BUSINESS :3 INDUSTRIAL ❑ PUBLIC,',SUPPLY. ❑ AIR /COND /HEAT PUMP ❑ FARM :` :❑ TEST /OBSERVATION b INSTITUTIONAL ❑ STAND -BY O ABANDONED i' ❑ OTHER (specify 13 AMOUNT OF USE YIELD SOUGHT, gpm /4� FROPLE SERVED jf /EST. OF DAILY USAGE gal REASON FOR DRILLING ,,.�..N11EW SUPPLY ROVIDE ADDITIONAL SUPPLY. aAPLACE EXISTING - SUPPLY .0 DEEPEN EXISTIN WELL CITEST /OBSERVATION DETAILED REASON' FOR DRILLING ® sc f i ': r� t rw WP Tli �o i on w ov w P ,s co WELL TYPE . DDRILLED []DRIVEN DUG, - []GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓.d0 IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ry0v M qr : Ah 4K-5 ay Address: PUh ✓r1 1164'. AI, IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:- YES NO 1, NAME OF PUBLIC WATER SUPPLY: Lg Pee l►SALl _: i_ j�Vd✓cy�, -e� �ls%f"ic OWN /VIL /CITY�q��! DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:. E .LOCATION SKETCH SOURCES OF CONTAMINATION PROVIDED /y ON REAR OF APPLICATION ❑O EPARATE 9,H ��/ dat (signature PERMITG�° Y TO CONSTRUCT - A WATER - WELL`7 k. 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_We11 in accordance with the requirements of the Putnam` County Health Department attached to this permit 3. Submit a Well Completion.Report on a form pr d by the.Putnam County Health Department. Date of Issue: 19 Date of Expiration: _15- ermit Issuing Officia Permit is Non - Transferrable ate copy: H.D. File, Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller 1_9`7 jack Kare!.% Director De-,).7rt%nent of Environmental. Health Carmel, N.Y. Re: Sunnysi.le 6. Oak Pi_.ace L,rzke Pee..,cs'd 11 9 N.Y. De ,r Mr. K�re!_I: This let-ter i-z ,.,'ri+.ten to -e-ve .,:s our form-,.I renuest th:n.t our re,uest for Der-nl,:sion to drill 0 the above premises be -)!.-Ced. on the ,fiend- o-:' the meeting of th- _'.1 " . rtient oi�' He,c!.Ith on Iyove-.,Tiber 1-6, at _) 0 -o.m. or any adiou_rnient thereof. Further, e re:--uest tX7t +.i---le for ':i -�res-ntu;at * ion Of our -'A-0 lica".ion fora v­;.riance to dig such 9 well_ be also reserved at saic'. meeting. Z�D Th -_ n'-,- ;-0u. Very truly yours, 74a Qe_� Norm,, 11.9 11,17.ssen P.C.x/.0 . '4 , . s f k f r� x r _ s -'r e, u: z$s `' '•. ia_ ^e�,k' S'¢ ,? of r ¢ ,& -sa,.: r� a',` d - '� r 7 , r - - F r .. l c 4 ? -o' F +mot• 5 6 1 'Y e �� V� ; 7 d �y I-- i' w 1. . -.. .._..> ,ti v--'t � ¢�t`{ .�•��. ,;. �e �Fy >,,,r.:a•pij» y� l qt ! x-tp m„ .r i ,r •.... j� lit i115i`'�. '-;+a »+a �, rya .r..� y� •.+"'&tom r ♦ w:. w4 ',I.,',•- 4 } a a p ;�g -r,J a '� �% O x: c% S� . 4 k i ¢:.q £ : ' it .:'¢ , yr $� > M° ''', yM1' _,7 t "i R DIVISION OF & HEALTH SERVICES x s John 'M. � Sitiinons �.: M. D L, ,•� e ". N Deputy Cccra►ussioner- °of Health k FMQiAC'rIVITY• REPORT y Shfeet:' of - 11 zr, `.i e P:sb x I�i` ".;- 3:� .� # k.; r ?i , x ;P :-sue° .i'3_,.., -" INSPECTION ' � ' Orig.:Routine UZ �.., k � _ 1 Ori lain • - 9 Canip. 4.1 �, ADDa_ _ , - 'S t1.NN u 5 l t� £: ` f - kN k i t:. _ 4 s, - orig Request . No. Street - Town - TM No: lCdrp'llance`^- 'I �, .; � `te a :'^ I <. � a �^•a" � :,3'�. m` - �'" .r '- `'" " e ldlnt 1. 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"n ,,. d r -.. ,..- }<1 " t 'i::{ , F, '.S. ,W i ...M /j % : i `, ' 'M, -. 4 11 2 u .'( '', ''"' V- M v a. .l e. ,a, `Y?,b ,; - ',1, fit, a° '{ .T •t ,I w; u `' Y -t. I. 4 h :::.. ,t'�s ,. . .: .u. _: �` 3, di a d•e: •�`+' �,fi _ f .'11.. - � �; t, + , ,x cu # vc„ b i. j'. 4 e 1 7`i` ? I! r ', t. . 5'? G ' « : % o-. ., ., �`.: .. .•.. .r �,. ,: j „k� ,..ry.., ,.r.4 ., .:K,.r' M1'.,. .7 `S{ `'^' ,” �4J _ .Y y f ,• . ,.a ., ., , ,: .,, ,,,. , .at a a,.,.y, .t,, :' �,. :,E D (, ,yY�2 , "y. L., c � - I ;: t 11 -� 1, , '' 5 0 ,•> • . "I �, � 4u - �, I I , , I— - . � - . � I . t. y �c , . 1, L , �, � - ,,�;-,�� �. , i�4 � , �.. , t. � ". , -, , ,�-' � - ;, . 1. k %'t 'fi ,-,- d n3 } a. Y V, , 4 r t ",'" "� �, �; # .. A'. .J eE`. e4�:av 11 t'- $ AA a "�; 7 , t r >< ti. �, ,, yt. p t 11 r, b.; >. f ,,. , C 1 )\ - r= ,, w vile., a .: 4 i y ,J •. R 1 t' P M ! ,.M1. ..Iv +2 A ,,. " ,..0 .,,. , 1,` 11, S N r rtto,d' P P ;`% it f Y 1 t' T,. r` , 1.1 s_ , .,v t 1 `wIJf ' gr,K Iq ee y:. t S fit,.. { - A t , I ,.. t ,_ , l A ,.. . e•"3 • off. R .G: :, w �-,� .:N..: , ...' ] awy n A P " rye' fe p. ! ,. .: , 11 - :, r, "` f '.rte #' -, 4 r , a+" <•'�s "-,•. _:w�-'..:�:,=�u =- •ism- -.... :�, = >:,, -- e:p;;,,7a:a,;.;.:.;r MARVIN O'DELL Inspector • 'PUTNAM VALLEY, N.Y. (914) 526, 2377 TOWN OF PUTNAM VALLEY BUILDING, ZONING,_ AND . SANITARY DEPARTMENT j October 27, 1987 - i Mr. Robert Morris Department of Health 110 Old Route 6 Carmel, N.Y. 10512 RE: TM #98 -4 -1 Dear Mr. Morris: The proposed well shown on submitted drawings does not conform to the. necessary separation requirements.. It should be noted that the existing drilled well on this site does meet necessary separation requirements and possibly could be extended. _� �- s..-, 3's' ^ "f^^ �.�,e,..- ,.. -L. .......y :; . ., ..y. .: a. _ ... - .. _ . ..,..q. -�r> •..�.•a. -.. ..-... .K,y„a.':.k,.: .,�.e .._, , _ .... .,. - .-.- -, � �j e ..q.; yr .. ,.. r..-•� <. c -,;c Very truly yours, MARVIN O'DELL Building Inspector MO'D:es ffj Iii. 33 DEPARTMENT OF HEALTH SAC. Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT i WELL LOCATION Stree Address Town Villa e /City Tax Grid Number WEL OWNER 2 e �aSA�S Mailing Address J/-- nc Ve Sk c°5� 1Y. /a yo C3Private DPublic SE OF WELL 1 - primary 2 - secondary G'RESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify) AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING ❑NEW SUPPLY 9134ROVIDE ADDITIONAL SUPPLY [I<EPLACE EXISTING .SUPPLY O DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING 0 sc ,p rat kle r �t caw '�P ni �zil IS *-A wn r a ✓ W f -" is o WELL TYPE ®DRILLED DRIVEN ®DUG O GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES w NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: NAME OF PUBLIC WATER SUPPLY:L41 Y V3Cly7 Address: DISTANCE To PROPERTY FROM NEAREST WATER MAIN: e f NO 1c*OWN /VIL/CITY4A tee s1 <1 LOCATION SKETCH SOURCES OF CONTAMINATION PROVIDED /v 7 ON REAR OF THIS APPLICATION �0 EPARATE �H dat (signature) PERMIT TO CONSTRUCT A WATER WELL ,Y 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 s.hal 1: 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. Date of Issue: Date of Expiration: Permit is Non - Transferrable 2/87 19 19 Permit Issuing Official White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner Oranqe Copy: Well Dr_i.11Pr � • t i � a.c„ �{ a,_ i � , <. 4 v �. �. �' S � ti2 � �� r� e^ '� �} f I ♦ I�F'l��n TO" 'liPeQ CJ !'rya R '%' 1' 4�;� 4:- ti+,.).L.�%� .PJ •`��r. 'fir >d. ♦.�^�wR w. • L ^'i 4` orb. R 1: r { z: - .,t, � .a� Y4„i. -:::F =<: z7.-: ",;; ;: �✓.'- . . yyS• °:��i tee. 4~ea....� .. ,a .. <- MARVIN O'DELL Inspector TOWN ®F • PUTNAM VALLEY BUILDING, ZONING, AND SANITARY DEPARTMENT Mr. Robert Morris Department of Health 110 Old Route 6 Carmel, N.Y. 10512 October 27,.198.7 RE: Hassen - TM #98 -4 -1 Dear Mr. Morris: The proposed well shown on submitted drawings does not conform to the necessary separation requirements.. It should be noted that the existing drilled well on this site does meet necessary separation requirements and possibly could.be extended. _ .TOWN HALL... . �JACLEY. c" • -�, (914) 526 2377 _-` „ __.,...:. _. .........� � o- .p..q_ .. ,.c.. .;�. o—_. —c.- . _,r F.--e �- '"nR`: .. �.. ,ro •Ad.�,...�c _�. .y ..... .. .. --: �. �q_ .p,. . -. ea --oe- _e.�. .• v4.> -�` Very truly yours, P 0 MARVIN O TELL Building Inspector MO'D:es 4tin vs - - ----------------- C> DEPARTMENT OF HEALTH Division of Environmental Health Services sic TWO COUNTY CENTER - CARMEL, N.Ye 10512 (914) 225 -3641 Prun PVPMTT .!Lt 1AI j 4 WELL LOCATION Stree Address Town/Vi lia e /City Tax Grid Number, WEL OWNER - •� a �� SC ;.. Mailing Address , rrt .gVe s r � . • /ado ®Private 0Public SE OF WELL 1 - primary 2 - secondary --iS IC IGIDENTIAL 0 BUSINESS 0 INDUSTRIAL OPUBLIC SUPPLY .:.. OAIR /COND /HEAT PUMP O FARM .O TEST /OBSERVATION U INSTITUTIONAL ❑STAND -BY ®ABANDONED D OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING ONEW SUPPLY W ROVIDE ADDITIONAL SUPPLY 04PLACE EXISTING SUPPLY O DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR .DRILLING 0 "_Sc f ff h q k/•e I e 'Qt jjeW wP A �C , y_ av we- o WELL TYPE ®DRILLED DRIVEN ODUG OGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name fY&M40 Ati Address: Pq4 m y IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: �4�e /t°rDS�il�13T*/1%V6✓ctn �1s%E'ic OWN /VIL /CITYV4 &e&51 <) 1, DS`�A.'�CE TO PROPERTY FROM NEAREST WATER MAIN:' � f��! K LOCATION SKETCH S ON v .:t dat OURCES OF CONTAMINATION PROVIDED REAR OF.-THIS APPLICATION 00 , A .(signature f' x PERMIT 44? 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 constructi n,V�" the applicant s.hal l� 1. Pump the well until the water.is clear. 2. Disinfect the °well in accordance with the requirements of the Putnaml�-!.. County Health Department attached to this permit. 3. Submit a Well Completion Report on a form pr d by the Putnam County.' Health Depar ment. Date of Issue: 19 :Date of Expiration: 19 ermit.Issuina Official Permit is Non - Transferrable te copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller m , ... 4 NOV 19?7 Mr. . isck Kar-el.1 V(�_t b r De--)-rt-ient of �vironmrntal_ He.n-'-th Carne' -, N.Y. Re: Surnysi-le 8' Oak Place Feeksril-1, N.Y. De-r Mr. X-rel-IL:' This letter i-.- ,%,,ritten to --erv-- -:s our for-ii ! I re-ues'u th:n.t our re-uest- for -oermi-,7sion to : ril.'_ 7,%Ie 1_1 0-n the ---::.bove premises be -,I­cs_d on the --:.-,,--nd of t! m a e t n-D of the De,�,-:rt-,iert o= Henith on D,ovember 1", —at 7:30a 10-11. or anir rn'djour-n-iant t'lereof. Furtner, we re­uesiu- tiir-t ti,-ie for ,n. rr-s-nt;:z.V on of our 'Ucation for a v--iliance to dig 7zuch !? weil be also reserver. = -tt s-.icl. meeting. T-',,-, 7. n--� you. Very truly Ir.'U"S, r Norm- .� Gee �% ���¢��� PUTNAM COUNTY DEPAR'iMW OF HEALTH Division of Environmental Health Services Program:�e Facility: /#Z) � Time: /Oe /6 Date: Telephone ms's Name: lw5 mAs5cAl DISCUSSION: U ®sr®A16- W44R(.. If- ° _ YA194,0 eAWAf®r :RF, OdMAIAOEV joy I AgQ ,e1441A,6- _ A95 HAs$EA bmft,49 Awg ® ®aa -Ag- &AAg geo.. -p-p gag ie gow/e 6. :.PUTNAM COUNTY- HFA�,TH: DEFARZMENI'.• . ':r .. DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Camnissioner of Health - FIELD ACTIVITY REPORT - Sheet of M �SS EN INSPECTION NAME _K Prig. Routine _ Orig: Complain ADDRESS 5 V NN S l7 ofi jC ?L _ Orig. Request No. Street r Town Im No. Compliance .„ / h _ Canplaint Camp MAILING ADDRESS S l_ A L & C € -A U E E ASTC N �S U (o � l _ Final P.O. Box Post Office Zip Code Group Illness Construction TELEPHONE__( "� .4 7'V q -• (9 21 ! ' Reinspection PERSON..IN CHARGE I, 1� -r-�, Field, Sampling Only OR INTERVIEWED MAN A - N!u [ " ` i`� Field onference ` Name and Title • 'I _ Other ' DATE I Z TYPE FACILI'T'Y rNV Pio iti( E TIME ARRIVED 101.3D TIME LEFT 11.3a j Explain FINDINGS: X31:© A'DULSE 2ED&ILLIP - of EY-ISTIJU&6 WELL i r INSPECTOR: (� Q�e�/ tSSG TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: LA C zp SOS9 w - 001 vo -I'l 3,?A 0 -7173 FA ti ki