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00769
PUTNAM COUNTY, DEPARTMENT OF.-HEALTH.
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE. SEWAGE TREATMENT SYSTEM
Owner. Address
Located at (Street) Tax Map Z q, Block Lot -7 5'
(indicate� nearest Cross street)
Municipality f Z 5 4 Watershed
. 7
SOIL PERCOLATION TEST DATA..
Date of Pre-soaking 7- f � Date of Percolation 'rest 7 Z 7 4el 2
-17 �f
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. :5 1 min f6r 1-30 min/inch, ,5 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from topof hole.
Form DD-97
XX
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NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. :5 1 min f6r 1-30 min/inch, ,5 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from topof hole.
Form DD-97
a Sheet Off`
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
YOB FIELD ACT)l<YITY REPORT
N A 1vfR ! Se- 14 a ,4.ci Tor. ,t! 1,14
acknowledge receipt of this report:
07/12/2002 09:48
BRUCE R FOLEY
'ablic Health Director
845 - 225 -9717
1NSITE ENGINEERING PAGE 01
00 f - K7,roc+
DEPARTMENT OF HEALTH
I Geneva Road
Brewster, New York 10509
LORMA MOLYNARI.. R.N., M. S.N.
Auociate Public Health Director
Direelor of Patient S& Victs
ATTENTION: KA f KGENE REED
All information below must be ft& completed prior to any scheduling. DATE: °z-
J VK-4 ('J-*"%0a , eJE.
ENGINEER OR FIRM: -151"W- PHONE N.- -Xz-5 -°t too 0
REASON:
DEEPS: PERCS PUMP TEST: 0
ROAD /STREET: _ N't5 /Epr 7-cW K5 ,`.r- i6f�du -P Ar. z:z-
TOWN: TAX ASAP #:
lel5�
SUBDIVISION: �uSKo4TE uJoySG LOT #: , �'
OWNER- _ CK06-4 'r-eTr*0 Acs 01041VJ0 A~
NY ,C' U CRTIEMA FOR JOINT RE'V'IEW AND WiTNES ING OF SM TESTIN
YES NO
O Proposed SSTS witluin the drainage.bAsin.of `?V.est.Branch or Bovds Corner Reservoirs.
13 Proposed SSTS within 500 feet of a reservoir, reservoir stern or control lake.
❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
0 Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
C3 Proposed SSTS for a Commerical Project:
It is the responsibility of the design professional to provide the above information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the
response. If you answered to any of the questions, NYCDEP must witness the soil testing. This
Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design
Professional and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility
of the design professional to schedule re- witnessing of the soil testing with NYCDEP.
,1 R (b O rou �oRrt. FOR MUM" USE ONLY
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DATE t 3;a TIME•
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SPECIAL DISTRICT INFORMATION
CISPIITEDAF
REVISIONS
SCNOOL
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