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HomeMy WebLinkAbout1989DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.31 -2 -31 BOX 18 1 rm r 1-1�1 X0 �. r ...� . . i` ; . -. �. . [SIN eo-ue 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 riT -ar PCHD PERMIT1: WELL LOCATION Street' Address 42 Eastwood Rd_. Town Village City Tax Grid;;.Number Brewster NY WELL OWNER Name Mailing, Address OPrivate Charlotte Fitzsimmons 42 Eastwood Rd.'Brewster NY 13 Public USE OF WELL 1 - primary 2- secondary ® RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT ; PUMP O ABANDONED D BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify D INDUSTRIAL U INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT.. gpm /# PEOPLE SERVED . /EST. OF DAILY USAGE gal REASON FOR DRILLING 10 REPLACE "EXIS.TING SUPPLY O NEW SUPPLY NEW DWELLING), O TEST /OBSERVATION 13. ADDITIONAL SUPPLY O DEEPEN.'EXISTING WELL DETAILED REASON FOR DRILLING Existing well low y id' WELL TYPE DRILLED Q DRIVEN QDUG' [:]GRAVEL 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 : POBox B,.., Brewster, NY 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 O ON SEPARATE SHEET (date), siahature 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 thirt; *. (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 drillin operations be contained on this property and in such a anner as not to degrade or of wis contaminate surface or groundwater. Date of Issue: © Z 19� /A?P2 Date of Expiration N i 19_ it Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller