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HomeMy WebLinkAbout0961DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. sca n yo u rd oc:;. co m 631 - 589 -8100 25.41 -1 -2'7 BOX 10 .. '� � �m z E .�} , . E , � . I I Pr , IN � r f ' 00961 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 "I'LICATION- TO-'-CONSTRUCT Jk -' WATER - WELL ) % y� PCHD PERMIT �k��(/ r�L 17-11 WELL LOCATION Street Address Town/Village/City 22 Garland Road, RR #3, Brewster,, NY Tax Grid Number ��, CSI .— / -- ace WELL OWNER Name Mailing Address Frank Burns, 22 Garland Rd, RR #3, Brewster, OPrivate NY10509 p public USE OF WELL 1 - primary 2- secondary ® RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL 0PUBLIC SUPPLY (]AIR /COND /HEAT PUMP OABANDONED O FARM (] TEST /OBSERVATION O OTHER (specify, O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. ® REPLACE EXISTING SUPPLY O TEST/ OBSERVATION ' O NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL OF DAILY USAGE ___gal 13 ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING Shares well with neighbor which is inadequate. 'WELL TYPE Ix DRILLED DRIVEN jQDUG OGRAVEL C1 OTHER 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 P. F. Beal & Sons, Inc. Address: 4 Putnam Ave, Brewster IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET 11/28/94 (date) tsignature) v Malcolm T. Beal, Jr. PERMIT TO CONSTRUCT A WATER WELL j 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 manner as not to degrade or otherwise conta spate surface or groundwater. Date of Issue: 2 / S� 19 Date 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