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BOX 11
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01076
ei t� ' Y w t r •�'' -;
°R V r -.3 " 8 ,< ` ] PiITNAM COUNTY 1)EPA1
Dlvielon of EnvlronmentalrHealtb
CERTIFICATE O z _;ONSTRUCTION COMPLIANCE FOR SE
{ F
r
� rLo�ted atJ /�• ,its a U N �1�'�4 ��/Q/aw r
V'.''31` ,fir , r R �4. � y \{ t `S "'•T� , n x - � {
i0wner /ippllcant 'Name .r Sa t h8 �' Forme
` Address 4;f � n 2• �� ��- '3 %/ _
r y
;Separate .Sewerage System balls by ; � S' � f '" '� �.- =' `
_-7
Coneisting of ,y .'` Gs
I
+ p,
N. t ",
,G'kix �zr�EnglneortMastProvid
l
DIS04 !.SYSTEM `<
�^ � Snbdivlslon Ni
/ Zsle
Permit,l6
., ! ,..�, tS.li.,
h`t ,
i
,
2'4ii
e J f 4 U
410-4-1
k -rtl VT ', l•t •c
J • r i -.c 1t . T 'v.4, i ,�; ,e nt.. r.. v .�
,��" l -.� ! > '? 4� }'` � .Tts ,*is t - ,`��
>Water Supply: }P Pabdc Supply Proms <� a 7 ° *, Address i {
c ` '
- J: or 1/ � . prlvate'SnpplysDrWed by�� ' fires - L�✓S^ � !�'�� `'
Ballding Type - / t- Cf •e uc� t ` # Has Erosloa Coetrol Been Completed? `r S r
t Ati "
t
,Nmnber of Bedrooms �— 'Has Garbage Grinder Install " ?
;Other Regniremente
s z rvY t c xx, �v S!x n`
Iycertify thet the syetem(e) ae l{isted serving he above `premises were corietructed esaenbially +as shown on the plena of the completed work:( „'copies
;of which are attiichedj and in accordance with the standar`de� ruIea and i la`tions in accordance vith the sled. plan and the permit issued by the
"Putn County Department Oft, Health
am
I. IG x �G4 1 N L Y Y 1Y jjC i4r 42 h.}i ". . • '�i 1'•� i . pEw /I R'.A
Date . .
A
License No
t: to x.
it ,4 Add�reu } , >i.µ t' 4,. x •' C Pik l Pa '. r t {wJ J` ti - f
..\_ E • . ]: „
V. o t w JY- ws �5.. . -..� r-v3 x: �, ^+�•.., vs- ,' v, •5 ,;� ; c , . , < .
Any pf rson'occupyinq premises sewed by the above. system('s) shalt promptly }stake wch,actbn'a} may be.nepfs�ry to aeura the coradion of any un'gnitary
;conditw�sresultingfrom +wch u's�ge Ap,'proval of! the feparate�sewssiage syster►i shell become null end void,ei eon at, a pubtL: Ynitttry Nvwr` tipcomef
:.
awilable ana theapproval of the jp►ivate'wate► supply�shan becomenulljanQ rtvoidj when a publk ,wale wpply: becomb avallabla Such appiov�ls are
sublecto` modif eatfon or change when in the Judgment`;of +the Com�lssionsi of Me t.iueh' revocitlon, 'modlfktion oi. clYnga is naeesyry:
cc':/ ! , s, f 1.•', nr .t` ti•�n yFS ' T s r. ,?i NSF
I !Date �U /��
yt
L
^f.
O
PUTMM COMM .DEPARTMW OF ..HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Sawn
Owner or Purchaser of Building
AtdQ1 Win Co S �
Building Constructed by
w 1.0tel ko a�
Location -.Str t
Municipality
Building Type
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM:
I represent that I am wholly and completely responsible for the location,
workmanship; material, construction and drainage of the sewage disposal system
serving the above described property, and that it has <been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations -.of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good.
operating condition any part of said system constructed by me which fails. to
operate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance ",.for the sewage disposal system, or any
repairs made by me to such system, except where the failure to operate properly is
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept. as conclusive �he determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act.of the. occupant of building utilizing
the system.
Dated this day of (% 19_,�:7
-.Genera -roatzaetor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature
Title
Corporation Name (if Corp.)
Agaress
13
Mrs. Grace SarrO
RD #2, Route 311
Patterson, Ny 12563
,jo,3 march 271 1987.
JOB * SITE: 50 Newburg Rd
210 Ft. Drilling @ij
49 Ft. Well Casing
Drive Shoe
Bacteria Wa
z,
ARTESIAN WELL CONTRACTORS,
Putnam Ave. Brewster, N.Y. 10509 19141279-5041
.;. A P 1� 8_1987 ............................ .....
Date.................. ---- -- * .........
Grace 878-9478
TOM 961-1000
Lake, New York.
per Ft. 1,680-00
0 per Ft. 441.00
60-00
�lysis 30-00
r -f 3. 2,211-00
ro
210
Ft.
Casing 49
Ft.
Yield 15
G214
Level 35
Ft.
R,
1.5
r1T,
46.
Thank you -
C06,
A�' ; WELL COMPLETION REPORT Office Use Only
...-.DEPARTMENT OF . HEALTH . :..._._ _
` Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
WELL LOCATION
STREET AOURESS: WNIVI 1 1 Y TAX GRIO NUMBER:
50 Newburg Rd., Putnam Lake.. Patterson, NY
WELL OWNER
USE OF WELL
1 - primary
2 - secondary
ADDRESS:
NAME. Grace Sarro, RD #2 Route 311 Patterson, New York. 12563 p Pl
0 RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /CONO. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 / EST. OF DAILY USAGE 300
REASON FOR
DRILLING
D NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATI
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 210 ft.
STATIC WATER LEVEL 35 ft.
DATE MEASURED 31271
DRILLING
EQUIPMENT
O ROTARY 12 COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. ® OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 49 fit.
MATERIALS: USTEEL O PLASTIC ❑
LENGTH.BELOW GRADE 48 ft
JOINTS: OWELDED 121THREADED ❑
DIAMETER 6 in.
SEAL: [.3 CEMENT GROUT ❑BENTONITE 01
WEIGHT
PER FOOT
19 Ib. /it.
DRIVE SHOE ® YES ❑ NO LINER: O YES
-
SCREEN....
DETAILS
.FIRST
DIAMETER (in)
-
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEYELO
❑ YES ❑
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH -ft.
BOTTOM
DEPTH _
WELL YIELD TEST If detailed pumpingIELL
METHOD: ❑ PUMPED ; tests were done is in-
0: COMPRESSED AIR , formation attached?
❑ BAILED ❑ OTHER ❑ YES ❑ NO
LOG 'If more detailed formation descriptions or sieve analyse
are available, please attach.
DEPTH FROM
SURFACE
water
Bear.
ing
Well
Oia-
meter
FORMATION DESCRIPTION
tt.
ft,
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Surface
an Dose led e.
10
2-S
__Xediun=harc1
fractured bedrock.
210
6
190
.15
25
.210
Hard qreV and black granite.
WATER :91 CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED. ANALYZED? t3YES ❑ NO
ANALYSIS ATTACHED? CtYES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME DATE
ADDRESS Mill Drilling, Inc.
Putnam Avenue
'sl t ^^
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
.4 't o
7.
BREWSTER LABORATORIES -
Box 224 - BREWSTER, N.Y.
(914) 225 -2072
- WATER ANALYSIS REPORT -
SAMPLE NO. 6509
SOURCE: Grace Sarro new well
Newburg Road
Putnam Lake
Patterson, NY
COLLECTED: April 6, 1987
BY: Mill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
April 8, 1987
Roy Bickwit P.E.
Director
UTNAM COUNTY HEALTH --DEPARDEW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Conmiissioner of Health - FIELD ACTIVITY REPORT -
Sheet of
-- INSPEC�9
NAME /y, .r G' G,o �%��j, �% rig. utine
�j Orig. Conplain
ADDRESS / ` � �'' y _ Orig. Request
No. Street Town TM No. Canpliance
Canplaint Crnip
MAILING ADDRESS G-�j Final
P.O. Box Post Office Zip Code — Group Illness
Construction
TELEPHONE —
Reins pect ion
PERSON IN CHARGE / �� / S ield, Sampling Only
OR INTERVIEWED Field Conference
Name and Title
Other
DATE % TYPE FACILITY
TIME ARRIVED / �? TIME LEFT / Explain
NDING.S :
INSPECTOR:
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Act�.vity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
,f
II.
IV.
V.
VI.
` FINAL SITE 'INSPECTION Date �;zA 'a
f Inspected 6 A-54
;CATION /� Zi�-ti 6 r-G• -� 1 OWNER �C�^`:" y
# I # OR SUBDIVISION LOT #
�, � � '' .
10
90 ME DISPOSAL AREA
a. SDS area located as per approved plans
b. Fill section = Date of placement
2:1 barrier_ LGTH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., reater than 15' from SDS area.
e. 100 ft. from water course /wetlands.
'
SEWAGE DISPOSAL SYSTEM'
a. Septic tank size 1,000 1,250
b. Septic tank ins evel
c. 101.minimum frm foundation
d. No 90° bends, cleanout within 10 ft. of 450 bend
n
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
An
3. Minimum 2 ft. original soil between box and trenches
S
f. JUNCTION BOX - ro 1 set
g. TRENCHES
1. Length required - Z -2- % Lenqth installed 2
".0 I've A/ •
2. Distance to watercourse measured. ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet from property line - 20 feet - .foundations
7. Depth of trench < 30 inches from surface
8. Roan allowed for expansion, 50%
9. Size of gravel 3/4 - 1 " diameter
10. Depth of gravel in trench 12" minim=
11: Pipe ends capped
h. PUMP OR DOSE SYSTEMS
1. Size of pump chamber'
2. Overflow tank
3. Alarm, visual /audio
4. P=p easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health-Department
estimated flow per cycle
Af
HOUSE
a. House located per approved plans.
b. Number of bedrooms
WELL
a. Well located as per approved plans
b. Distance from SDS area measured ft.
C. Casin 18" above grade.
d. Surface drainage around well acceptable.
OVERALL WORKMASHIP
a. Boxes properly grouted
b. All pi22s partially backfilled
c. All i s flush with inside of box
d. Backfill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall protected & dir.to exist.watercours
g'. Footing drains discharge away from SDS area
h. Surface water protection adequate
i. Errosion control provided on slopes greater than 15 %.
�, � � '' .
10
Rev 3/86
PUTNAM COUNTY Di Pfi
- r
Ssaleeei'tn Provide Permlf'q :' ..
oe CEBTMCATE;OF COMPLIANCE -:—
I represent that I am wholly, and completely responsible forFthe design "an
above described will beiconstructeC as shown on the spproveC amentlment
County Oepa`rtment 'of' and that on completion thereof a' "Cert
be submitted'to the. Department; and a .wntten.guarantee w,ll be furl
Pa
ce in good.operating, conddion any,.pait of said sewage disposals
ante: of the - epproval of the Cerhf,cate of Con ;tiuction`Compllancel.i
will be located as shown on the- appr("?ved:plan and;that said well wikbe ini
County Oepartmentof kealth:
Data 91 5 ned
Address aY-
APPROVEO.FOR CONSTRUCTION This'approval,.'expves.'one yea :fro
revocabletforcause miy.' amended`ormodified , when.eonsidere net
requires w p ved for disposal 'of'domestic san!
t
Date BY
.
ion oftfie' proposed systein(i); 1j, that tne`separate' swage Disposal'system
to and in accordance with the. standards rules and regulat ions of ' u ham
of Construction.Compliance" satisfactory to . the_Commissloner of Health�will
the owner, hii successors,_,heirs or assigns -by the builder, that said builder will
during tie period of two'(2) years immediately following the Cats of the iisu-
original system or any repairs thereto; 2) that the drilled well described . above
jri. accordance' with. the standar s, ru s- on regu aZ ooff the Putnam
P.EE.. a /!_ R.A.
G tense No-. '
.. v
te issued unless construction of the building has been undertaken and is
by. the .0 midsioner ot`tlealth: A Change or alteration of construction
and /or Mz t n 0
�-
T it le
-�+c : r - -.�,, .. -er -. -°+ +--r", _ .••ay-- -.'ri -�' F.. rte-- r— - ---c, -
FUTNAM COUNTY DEPARTMENT OF HEALTH + �\
Rev. 3/86. �1t, Dl vleionofFviromnentalHealth Servlces Carmel, Y 10512 Engineer;toProyldePermltlY.
s • tln CERTIFICATE OF COMPLIANCE
CONSTRUCTION PERT F, R EWAGE, DISPOSAL SYSTEM Permit
MI
f6V ;.
® wFRI
MVIRTA
IMMVAFI� MAMA
Ot6F Requirements
represent at. 1 a7; -Wholly and completely responsi lefor•thedes' antl 1 a of the proposed'. s erh(i)1 1 th th 'se ate sewage disposal system
above described will be constructed as shown on the pproved, amend an r to and in, accordance it the itan' ar rul s an regu a ions o a u nam
County Department of Health, and that on.com etion thereof a'.t ertd' `e '.of Constructor Co pl nce satis ct ry, o the Commissioner of Healthwill
be submitted to the Department, and !a lwritte ,guarantee,w�ll'be ur eG,the owner his sucee heirs of assiy s b the,Duiltler, that sbid builder will
place' "in gootl operating condition: any part o ,aid sewage tlispor stein quriny the per ad' of � 0'(2) years tm edi ely following'thatlsts Of the Issu•
an of the approval of the Certificate of C nstrucUon Complian oflthe original system or;any repairs theroto• 2) that this drilled well'described above
will be located as shown on the approved plan d that said well will be nst It' in acc0►dante with the' sta Bards, r las nd regulations- 5f the Putnam
County Department of Health
Date . �/ -�Z - p �0 ,Q Signed' P. E. R.A.
Adtlress License No' SG �4
APPROVED FOf2'CONSTRUCTION: is approval expges one year- ' from the date, issued unlash can'
ohstiuction of the building has been undertaken and Is
revocable for cause or may be amende or`madified, when considerednecessar,y by the`Commisiioner' of Health. Any change or alteration of construction
requires a new permit. Approved f disposal -of, domestic sanitary sewage;'antl7or p6 to •.water, supply `only.
Date by Title
K.
i •RANDOLPH W. LAUCRENT JOB No......•865�
73 FAIRF ELD ASSOCIATES, SHEET No.— - OF t
P ATTERSON42 g 6 1 8 RK1256*3 COMPUTED DATE 12-.7'
-- - .
-
CONSULTING SITE ENGINEERS CHECKED BY %Z 4/t— DATE
SCALE
i..............
: I
;
. ;' .) .i... �`., ^, f i. � {..:_.j..��is�!N' jl_��t'�j..� f }. %StS��.`�i�_. � - �..• � .. .� I �j- ..�. _ � ..I � �_.. .._�... _ l.. _l
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1
:
i
oats 100' -1- 2- aa' _
fad
TO:.
USA � Yp1?0�,�7•IG a.lupGL C�sPSS
• 4, ;. - i' pp'mm COUN'T'Y DEPARTMERr 0F,1 L, 'f'' ;► i7 ' . : • .
DIVISION OF HEALTH SERVICES
DESIGN DATA S =r- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
owner. C, Address lxlsFm ,a Pr. PA i1 FRAO/Y . N! R RC
Located at ( Street) R cp J4 9 0,4 Q 5 Block �_ Lot
(indicate nearest cross street)
Municipality �i4 % % 6�QSO iY Watershed CR y T O N
SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATIONS
pate of Pre- Soaking % - i(3 - g - Date of Peroblation Test
HOLE .
NUMBER CL= TIME - PERCOLATION- - PEP(JOIMION -
No.
Time
Start -Stop Min.
4 _
5
Ground Surface --
Start Stop.
Inches Ir ches
In Inge
'Drop •In
Inches
Soil Rate
min/In Drop
z 12 is z 3 • ' 1# zy
7. 4
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are'obtained'atreach percolation test-hole. All data to be submitted
for.review. '
.2. Depth measurements to be made fram top of hole.
SU W' PTEST PIT 6.-A° REQUIREC$0 BE E APLICATION ,
DESCRIPTION OF SOILS ENOOU[yTIItED IN TEST HOLES ,
DEPTH • HOLE NO.. / HOLE NO. Z _ HOLE NO: • 3
G.L. .
- 5A&P ✓S 16 : "y /a/voY s:I�ry -,4NDN/ -S 1.rY
2' LOAM wl S'oivts eol4 w - sroN,Es 1(5/-1M `^� .STUN�'�'
I3ovco��es Bo�cvrRS 13OULPER.S
3' i AAcrs of CcAY Ac,Cs of r-,1AV %ACES of OA Y
T /- �Rovy //ou; •Tj /,QvuC�r! Uv; - - T,y/�p�cji� Our
4'
OCK
10' -
12'.._
13' ... e
14'
INDICATE LEVEE. AT WHICH GROUNDWA NSR IS ENOOUNTEEZED
INDICATE LEVEL, TO WHICH WATER RISES AFTER BEING ENCOiJNTERED-
DEEP HOLE OBSERVATIONS MADE BY:_ gl G l` W RO L4 ARk DATE:
DESIGN
Soil Rate Used 9- /0 Min/1" PI -op: S.D. Usable Area Provided
No. of Bedrooms 2- `.::;)tic Tank Capacity JOoQ gals. Type GoNc.
T
Absotption Area Provided By Z Z -� L.F. x 24" width trench
Other
Hof NFy,y
Nal»e _l(A /VOv(XN W I-/ / RF/✓i /I I'0c.; , Signature
Address - 73 i9l R F/ r6V V. - ORiVE 7 SEAL �
. ire �
I2,4rr f-9 j olil N y 12,5-6,3 ri -
11AS SPACE FOR USE BY HEALTH DEPARDT -M ONLY:
v
��FESSIONP
Soil Rate Approved sq.ft /gal. Checked•by Date
I '
wjw, g -- gw t
*1'225'm 'WIN-0 ly- MAE -!I MOM-0
M- I
PUTNAM COUNTY DEPART� OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE'S342AGE DISPOSAL SYSTEMS
,(Name of Owner.)
A---'-'� 0,-7
required _
60 ft. max.
REVIEW SHEET - CONSTRUCTION PERMIT
DATE REVIEWED: IaZ..;!10�
BY:
(Street Locaifion)
YES NO DOCUMM
X Permit Application
Corporate Resolution
Plans -.Three sets- S/s
Engineers Authorization
si§h-DR—aS DDS) SUBDIVISION
O
..........
J
'e-1
of Property Located
Property Metes & Bounds-
House Setback Necessary (Tight lot)
House Sewer - 1/4"/ft. 4"0; Type pipe
No Bends; Max. Bends 450 w/cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
101 to P.L., Driveway, Large Trees
201 to Foundation Walls
100' to Well; JQQ.�D.L.O.D, 1501 pits
100' to Stream, Watercourse, Lake (inc. expan)
151 to Drains-Curtain,Stom,Leader,,Footing
251 to Catch Basin
101 to Water Line (pits-201)
Septic Tanks
101 ran Foundation
501 to' Well
151 Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex-approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
Deep Hole Log, Perc
Consistent Perc Results (3) Fill
cd
-) r
House-Plcns-m-Two-sets--aff Pwi -t6r-U61i ai . -
Variance Request
MUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench/Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two-Foot Contours Existing & Proposed
Driveway, & Slopes Cut
Footing/Gutter Curtain Drains
Perc.& Deep Holes Located
Representative of Sewage & Expapsion Area-
Expansion Area; shawn; gravity flow,suff. size
If = Pumped Pit & D Box Shown & Detailed
-go e 1 No. of :Bedrooms
g
f mac,
Z
A
ly
Ir
C:9
O
..........
J
'e-1
of Property Located
Property Metes & Bounds-
House Setback Necessary (Tight lot)
House Sewer - 1/4"/ft. 4"0; Type pipe
No Bends; Max. Bends 450 w/cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
101 to P.L., Driveway, Large Trees
201 to Foundation Walls
100' to Well; JQQ.�D.L.O.D, 1501 pits
100' to Stream, Watercourse, Lake (inc. expan)
151 to Drains-Curtain,Stom,Leader,,Footing
251 to Catch Basin
101 to Water Line (pits-201)
Septic Tanks
101 ran Foundation
501 to' Well
151 Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex-approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
�a� DGOD r�.,f�'°,
__ '�
S� �' ��f � � ��
��� -w y
��'v �
a,
SION. OF,.,.
ENVIRONMEN
;HEALTH 'SERVICES"-
1PESIGW. SEWAGE DISPOSAL`,SYSTtq- TILE NO.
owner RA_. SA R"R Address
1961S�a j9r. PA TIFRsOIV N.Y.
Located at -(8EreeE) /f Sec. Block Lot
(indicate nearest cross street)
Municiipality P/ q %% ��Qso Watershed CR y76) IV
SOIL,PERCD=ON T= DAM. REQUIRM M BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking 7-ZiO`O Date of Percolation Test.. HOLE
PERCX)LATICN
NLMM al= TIPE PERMIATION
Run Elapse Depth to Water From Water
..Level
0.
im.. Ground Surface In Inches S6il Rate
-Stop. Min. Stop
Start start Prop.ln. Min/In Drop .
-inches Inches Inches
2 2-7
3e
2-7 /0
4
5
7-
2 2
3 7
4
5
2
_,:.2 1
3'
d OvtO,c Rs
.TRAc rs of c4AY
.. ... TirRovG.NvuT
4'
5'
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DEEP HOLE OBSERVATIONS MADE BY: Sl c 11,4,k (% LL A!l k DATE: %-/e' gc�
N DESIGN
Soil Rate Used 9" /0 Min /1" rt-_-op: S.D. Usable Area Provided
No. of Bedrooms Z S•,:.,ptic Tank Capacity JOOC,i gals. Type GoiVc-
Absorption Area Provided By 2Z L.F. x 24° width trench
Other.
Name fAlyoocm tic% z- / *y RFA1 l sso�.4 pc. Sig nature..
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ON /1/ Y /Z,5"6,3 1 � �Uj
'17-1.IS ,SPACE FOR USE BY HEALTH DEPARUMM ONLY:
Soil Rate Approved :sq.ft /gal,
PV
Checked by - Date
\ 'RANA SSOLPH W.
ES, p C ENT
EPATTERSON NW YORKA2563
914 278.6108
CONSULTING SITE ENGINEERS
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