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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