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WELL COMPLETION REPORT Office Use Only
DEPARTMENT OF HEALTH
-Division Of Envir-enmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET AOURESS. WNI IL a TAX GRIO NUMBER:
WELL LOCATION 0 akf ield Road, Putnam Lake, Patterson, NY S1� -�;
NAME: ADDRESS: MWBIVATE
WELL OWNER STIX BUILDERS, INC. RD6 Ball hack Rd., Patterson, NY ❑ PUBLIC
USE OF WELL ME RESIDENTIAL ❑ PUBLIC SUPPLY D AIR /COND. /HEAT PUMP D ABANDONED
1- primary ' O BUSINESS ❑ FARM O TEST/ OBSERVATION O OTHER (specify)
2 - secondary O INDUSTRIAL ❑ INSTITUTIONAL D STAND -BY D
MOUNT OF USE YIELD SOUGHT 5 gpm. 1N0. PEOPLE SERVED, 3 to 5/ EST- OF DAILY USAGE 300 gal
REASON FOR jffl NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY D TEST /OBSERVATION
DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA WELL DEPTH 200 ft. STATIC WATER LEVEL 117 ft. DATE MEASURED 9/16/88
DRILLING- O ROTARY #X COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT D WELL POINT ❑ CABLE PERCUSSION D OTHER (specify):
WELL TYPE ❑ SCREENED D OPEN END CASING. JM OPEN HOLE IN BEDROCK D OTHER
TOTAL LENGTH 42 ft. MATERIALS: XRSTEEL O PLASTIC GATHER
CASING LENGTH.BELOW GRADE 41 ft. JOINTS: ❑ WELDED ARTHREADED ❑ OTHER
DETAILS DIAMETER 6 in. SEALX® CEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT 19 lb./ft. DRIVE SHOE DYES ONO LINER: O YES ❑ NO
SCREEN DIAMETER (in) SL07 SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED?
DETAILS FIRST _ O YES ONO
SECOND HOURS
GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM
0 NO SIZE OF PACK in. DEPTH ft. DEPTH It.
WELL YIELD TEST If detailed pumping WELL LOG
It more detailed formation descriptions or sieve analyses
YY are available, please attach.
METHOD: 0 PUMPED i tests Were done is in- DEPTH FROM Water Well
XX COMPRESSED AIR ,formation attached? SURFACE 8ear- mia' FORMATION DESCRIPTION root.
O BAILED 0 OTHER ; 0 YES O NO ft IL ing Inter
WELL DEPTH DURATION DRAWOOWN YIELD Surface 20 Hardpan & boulders
It. hr. min. ft. gpm.
200 6 - 150 100 20 200 1 1 Medium to hard grey &.white grarite
WATER XCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
0 COLORED ANALYZED? #YES ONO
ANALYSIS ATTACHED ?XjYES O NO STORAGE TANK: TYPE Diaphragm
PUMP INFORMATION CAPACITY 62 GAL. 17
TYPE G» hm a r G i hl P CAPACITY 1 0 WELL DRILLER NAME I DATE
��� MILL DRILLINfoe C. 10/10/88
MAKER Goulds DEPTH A90 ADDRESS Putnam Avenue SIG
MODEL 10EJ07412 VOLTAGE230 HP3/4 Brewster, NY
R M. ill, resident
Rev.. 3/86
/to
- CER Tl
Located at
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Camel, N.Y. 10512
Engineer Must Provide P-67-87.
P.C.H.D. Permitp — =—
Name STIX BUILDERS, INC. Formerly SAME
Mailing Address BOX 304, E. BRANCH RD.. PATTERSON. NY Zip 12563
TOWN -OF- VATTERSON
Town or VWage .
Tax Map 25.54 Block 2 Lot 22
Subdivision Nam e8MA WSubdv. Lot k MAP 149E
Date Permit Issued 7/23/87 • RENEWED $/28/89 AND
7 24 91
Separate Sewerage System built by R.F. BRILL EXCAVATING Address 141 LLER STREET, R.R. 2, PAWL'I NG, NY 12564
-'Consisting of 1000 Gallon Septic Tank and 341 L F OF 2-FT.-VIDE ABSORPTION TRENCHES
Water Supply: Public Supply From Address
or: X Private Supply Drilled by HILL DRILLING INC, Address _ PUTNAN AVE., BREWSTER , NY 10509
Building Type WOOD FRAME Has Erosion Control Been Completed? YES
Number of Bedrooms THREE (3) Has Garbage Grinder Been Installed? NO
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regu tions, inonca wit the filed plan, and the permit issued by the
Putnam County Department Of Health.
Date NOVEMBER 9, 1992 Certified by r P.E._R.A.
Address JOSEPH ZARECKI, P.E., 6 ALBEIT AC 1 T, tLVLING NY 12564 License No. 61468
Any person occupying premises served by the above system($) shall promptly take such tion may necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shat ecom null nd void as soon is a pub:'-..sanitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner o"ealth, such revocation, modification or change Is necessary.
Date
0
i v
s
_. ........_ . - BREWSTER- LABORATORIES— .._. _.__ .... -- ._--- .-- ............. _.. _. _..__.. __ _......_.
Box 224 - BREWSTER, N.Y.
(914) 225 -2072
WATER ANALYSIS REPORT. -
SAMPLE NO. 7094
SOURCE: Elting & Mill (Stix Bldrs, Inca new well
Oakfield Drive
Putnam Lake
Patterson, NY
COLLECTED: September 23 1988
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.
September 29 1988
Roy B ckwit P. r'
hector
•,Y
PUT'NAM COLUrZ DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMMTAL HEALTH SERVICES
STIX BUILDERS, INC. 25.54 2 22
Owner or Purchaser of Building Section Block Lot
STIX BUILDERS, INC.
Building Constructed by
OAKFIELD DRIVE
Location - Street
TOWN OF PATTERSON
Municipality
WOOD FRAME
Building Type
8TH MAP OF PUTNAM LAKE
Subdivision Name
7224 -7231 (Map 149G)
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 can
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 imade 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 the determination of
the Director of the Division of Environmental 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 the building utilizing
the system. �a
Dated this 6th day of November 19 92 Signature
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
rev. 9/85
mk
Title Owner
Corporation Name (if Corp.).
Miller Street, R.R. 2
NY 12564
Address
y/yOU t�A� *vim 1 � - --
Call" , I� llwNo lre�lt/
Dlelfiwat�ereif�aMalBaaMf 11'Y lSl?
�W
101�l'!OS'>POiYA616 DIPlOSAL`Sl�11N1 ' - P�-67 87,
TOWN OF_PATTERSON
OAKFI:ELD DRIVE.
.. 6aa�ld d , . -
� � 8TH MAP OF PUTNAM `MAP #1.49G 53. " S' . 7224 -7231
Q....a X
O� 0! � per_ STIX•BUILDERS .fNC pe J
ti . Drde o[ �r OR I G ,t 7/23/.87, ,RENEWED •8/28/89
)Maw A"M BOX, 304, , ;EAST BRANCH ROAD b Tom �PATTERSON ;:: NEW YORK. i i 2563 `
Datp Subdivision An>;roved Fee Enclosed 0 amni,nr
4.
Tn.- WOOD FRAME : a � tk ACRE. F�Seetle.0oy 2 FT `r�e300 C.Y.
' ' THREE'
NataMa 1 �iea�a 3) p per 600 1s Rewared wba s la a=siMed
p G',! D Pin NetlOcatled FIO
$aredla S `ea�alfR 1 1000 rn.ls..k Iti�k .s 340 L F OF 2' ABSORPTION TRENCH
ea�ats�a/ad bj TO ,,BE DETERMINED' Adlheaa
q.
Ti M ?
WiMr Srtii Addresi
ltMr PYee
on, ..WELL Palifile :'� MILL' DRILLING i NC aaa..�
1 represent that 1 am wiioily anit eonipNtaly responsibN for tM deftn and location of the propoud syRam(q: 1). that the:nparatf saw Ai oi`iyftem
abovi deiaibed will be constructed as shown orb thi app,!oired 8m4ndment tfiae to and iii according with the its*W416 rules aff rpulii uinim
Oooty WYartment of• ►IMNh,' and, that on completion thenota'�Certfficate of,Construetton ;Comolamr, satisfactory ;to,t . Commissioner of Mrltliwill
M ai"Itted.1 'toil i �O41jish nt. arfd 'a wrtttai;.f)uaiantN ' wNi be - fiiAlsfiaal,66 owner 'hia.iuceea0rs, 4WS or SWOS by the bifildar, tMt tall Dulader will
wq in alodd oparatMls ati WkMn' "MY O of pi0' sOwiis' diso6s c syiteM'dwigQ the'peridd oi two (2) yaws bniif latily foll0whij thaditO of the Isau.
Mis .of the'appeetal Of" the CMtifkate 41 Cantruatfon Compliance of ,the "iml system o► eny tipaMS ttw�utoi 21 that tM'diNNO wil 0esaleW „above
wNl N bestoA ti slfofira ofi ttie'app►oiii0'pMn iiidtlwt sifit:wNl will tii.MSte1 in :ice”
" "ith lM''ftan0►dt, rule' aiid ri�uTaiToes � of , Apse •Putnam
county Oepartstsrft'0f 1Wtth ' ,
JULY .15 ;1991. si�fw —
_ � •.., P.E..g ., RA.
6 ALBERMAC .COURT PAk N =12 4
;� , Aadrest ticenM Ne 61468 :-
APPP20VE6 ROR CONSTRUCTIONt TbN appro�ial es.pMat two 4 tM date'1 u lie itrocilik of tfis pulldhq Air rein, undertake► and If
reVOeabN for eaxM er: Yoe. 111M10e0`a. modnlap whin,co iy by tile': nilsifOM1 of FIMtt11 '.Any•Charge or altMiltwn of oomtruction
falgiree a-7M Tn. ppow/ for disposal of domMk It •nd/ W t iter. . supply only.
Rev ok� `.T �l �r U,/ 6� % Title
10/.88
w P[fli�1M �UIJI'Y DE�AR'!ME[8T OF HEALTH .... .
.DIVISION OF .HEALTH SERVICES
DESIGN DATA sHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner STIX BUILDERS, INC. _ ,Address Oak:field Drive, Patterson, NY
Lomted at (Street) Garfield Drive Sec. 53 g1ock5 Lot 7224 77231
(indicate nearest cross street) "—
Municipality Patterson Watershed
SOIL PERCOLATION TEST DATA PIXXTMM TO BE SUBMIT= WME APPLICATIONS
Date of Pre- Soaking June 3, 1987 - Date of Percolation Test June 4, 1987
HOLE
NLEM CLOQC TIME _:: •, . PERCOLATION PIItCQIATION
Run Elapse - Depth to WaterFrcm Water Level
No. Time Ground: Surface In Inches Soil Rate
Start -Stop Min., Start stop Drop In Min/In Drop
Inches. Inches Inches
#1- 1 10:50 -10:56 6 24 27 3 2.0
2 10:57 -11:07 10 24 27 3 3.3
3 11:08 -11:15 7 24 27 3 2.3
4
5
#2- 1 11:01 -11:20 19. 24 27 3' 6:3
2 11:21 -11:41 20 .24 27 3 6.6
3 11:42 -12:05 23 24 2.7 3 7.6
4
5
2
3
NOTES: 1 ' >::. 'Tests _ to, be `repeated at same depth until approximately equal Soil rat p4
are ",&taified at each percolation test hole. All. data to be sulmitted
for review. 1
2. Depth measurements to be made froze top of hole. i
- - r
rev. 9/85
. J\i
4
( i
2' SANDY LOAM SANDY LOAM
31 WITH STONES & CLAY WITH LARGE STONES &
4' TRACES TRACES OF CLAY
5'
6'
71
8'
g'
10'
12'
13'
14'
INDICATE LEVEL AT' WHIat -GROUN Q7ER IS. M=UNTERED_ NO WATER ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AE"I'ER BEING ENMUNTEREA N/A
DEEP HOLE OBSERVATIONS MADE BY: ANN MARIE BRADY DATE: JUNE 4, 1987
DESIGN-
Soil Rate Used 8 - 10 Min,/1" Drop: S.D. Usable Area Provided 1000 SF
No. of Bedroans 3 Septic Tank Capacity 1000 gals. Type CONCRETE
Absorption Area Provided By .340 L.F. x 24" width trench
Other
Name JOSEPH ZARECKI, P.E. Signature
Address 3 East Main-Street Ste,
Pawling, New York 12564
61
SPACE FIR USE BY HEALTH DEPARUTM ONLY:
ZA 4q
F
Soil Rate Approved sq.ft,/gal. Checked by V Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #P -67 -87
WELL LOCATION
Street Address
OAKFIELD DRIVE
Town/Village/City Tax Grid Number
TOWN OF PATTERSON 53 -5- 7224 -7231
WELL OWNER
Name Mailina Address 12563 Private
STIR BUILDERS INC. BOX 304 EAST BRANCH RD. - PATTERSON.NY O Public
USE OF` WELL
lz�/ - primary
2 - secondary
® RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 ABANDONED
O FARM 0 TEST /OBSERVATION ❑ OTHER (specify
L3INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED 3 - 5 /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
MNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST OBSERVATION
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
NEW RESIDENCE
WELL TYPE
®DRILLED
DRIVEN ODUG 11 GRAVEL C3 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 8TH MAP OF PUTNAM LAKE
Lot No. 7224 -7231
WATER WELL CONTRACTOR: Name MILL DRILLINGS INC. Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: n/a TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: N/A
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION ..X SEPARA E SHEET- ON PLAN APPROVED BY
July 15. 1991 / _jr�- ' �7 PCHD 7/23/87.
(date) (signature)
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 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 provi ed y the Putnam. County.
Health Department.
Date of Issue: /2, 199
Date of Expiration: 7 19
Permit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
[ t l
N
l CON UCTION PERMIT FOR-SE
PUTNAM'COUNTY DEPARTMENT OPHEALTH 4
Dlvlston of EnvirossmotitalHealth Services Carmel N Y 10512 '' ' Engineer to Provide Permit#.
on CERTIFICATE OF COMPLIANCE
Permit 'N P '67 87 "
'AGE DISPOSAL SYSTEM.
v - - Town 'of Patter's'on
-= - -I -- Located at .Oakfi,eld Drive . _ Town or, vimge
l
on Name 8th:Map'of,'Nutnam..'L.ak' Wt .Map ��1'4?G` Ta: 53 slack 5 �, 7224:- 7231
Renewal ?�T Revtsloo
owneiJApplt«tnt Name. STIX,:BUILDERS-, INC = ❑
Date of Previoas Approval '
7/.23/87-
MallingAddress R.O. 6, Ballyhack Road Town Brewster, New York �p 10509
dla 3 Let Area 600 GPD F� P�CHD Nodflaitlon is Required 2 ft .Volume 300 C
N= g t B i w t' y Daubed When Flll is completed
13� Wood Frame 1/2 Acre
her of,Bedroome Desi n,Flow G P D
Soparate sewer.ge.Systemtoedaetetof 1000 Gallon•SepticTenk.ana 340 L.F. of 2 =feet absOrptien trench
To be rnaetrdcted by -t0 be determined Addreea
Water SUM:;,: Pdbllc Supply From ... Address
�.
orr WELL, Private Supply DeWedBi't0 be determine ddeess
Other Reoairements
%1 represent-that 1 am wholly and toinpietely•resporisible for the design. and; location of. the proposed system(s); I that the.saparate sewage tlispo_ sal s stem
above described' will be constructed'as shown on trio approVed:amendment,��iere to grid in accordance with the standards, rules and regulations oi-1 Tnam
County -Do partment of Health,, and that oWcompietion' thereof a "Certificate of Constructlon%Compiiance" satisfactory to the Commissloner'of Healthwill
be, submitted fo'the Department,, and
,a' "written guarantee will,be furnished, the owner his'.successors, heirs,or assigns by the builder, that said builder v�iill
place in' good operating condition any pa rt of acid sewage disposal system during "the period of two t2) :years immediately following thedate'ot the lssu-
ance of.the spiprovaI.of the Certificate of Constiuciioh.cii liarice.of .the original system "or any repairs thereto; 2) that the drilled well described above
will be located -as'sfiown on the'approve'd plan and that said welt will be Install in acc . an ` with t . standards, rules and regu;T ons of the Putnam
County Department of. Health,
Date,
::1 Signed . P.E. _X— R.A.
..9R9'.:.
(� Address 6 AlbermaC Court P li .. Y 12564 �ICe se'No 61468
APPROVED FOR CONSTRUCTION This approval expires two Years :from the to issued u eis construction of, the building has been undertaken and Is
revocable for cause' or may be amended or' modified 'when;constdered�necessar y. by the�Commissionerot:Heelth, Any change or alteration of construction require new permit. Approved for disposatQOf domestic samtsiy sewage,'an Ar water supply only.,
Rev: 2 /. B --�
1/81 Datr� e
D
Titl ,
M3
'� � '` PUTNAM�COUNTY -DEPAR tTMENTOFHEALTH , , ' x 1 '
Dlvhtid "p otEnvlionmentaTHeWth Services Civmel, N.Y 10512 .EnBinear to Provide' Permit 11
CERTIMATE,OF COMP
x
;.
ONSTRUCTION PERMiT FOR SEWAGE';DISPOSAL SYSTEM .Permit' q k g
Pat
_. .: teison ;
I,ocatadat Oakfield Drive Town er village
�sohal.iabo.x.ote 8th' Map 'of Putnam Sil jot dap #149G T� 53 Block 5 Iuc7
'Lake :.
224 7231
,Renewal ❑ Revision ' ❑
Owner %Applicant Name STIX` BUILDERS,. INC?
Date of Provioae _Approval
e Addr R D; 6, Ballyhack 'Road Town : Brews -ter tNY �p.10509
Bandme Type Wood. Frame Iot great 1 /2 `Acre : Ful SecutlgOnly " ' ' neptb 2 f t .!Velnme 300 cycy
Nnmber of Bedrooms 3 Design Flow G P D. 600 PCHD Noflticatlon'Is Regtilred When FM le rnmpleted -
Separate Sewerige.Systeat to consist of }OOO Gallon Septic Tank ind 340 L F of 2 feet ab "Gornt i on TT en f"
TO.be constructed by t0 be - determined Address`
Water SapPb, Pah1lcSapply:From
Address
or: 'Well r; Private Sappiy fhWed byt0 be:` detezmJ neC�ddreee
4
Other Renoiremente
I,repcesent ,thbt'I am wholly and "tomp let 61y resp6Aible for the tlesjgn.and locetion of the proposed system s) 1) that the separate , -sewage ,dispose l.systam,
above destri6eG'wJl be'constiucted as shown on theapproveC'smendment thereto and 1!yaccordance with' the stantlartls, rules and regulations o e' u nam ,
County 0epaitment of. 4 Ith;'and that on completwn thereof fa Cert�f�cate. of Construction.;Compliance sat�shctory (0.tha Commissionei'of HealthWill
be submitted to the Oepartrnent and a:;wntten� +guarantee' will be furnished:'the owner his wccessors .heirs or:ass�gns by the builder that said buildor'%vill
r
place: �n 'good,.oDerating contlition any part of ssjd sewage d�sDOSaIF system,dunng ttie per�od:of two (2) years'•(inmediaCely following the date of the !sw
once "df ,the .approval';of Gthe,Ceitificate of ,Const uctionrCompliance "of tli ;originaliys", ocany ropairs thereto; 2) that :the.tliilled well'.diikribetl above j
.will De located asshown'on,the. approved >plan andsthat said. well willbe,lnstall in' accoid c ith .the andards,:utes''and iegu aTions.' -Of -the 'Putnam
County Department of .Health
Date z. h. F i Signed t P E R
A
June 9, :1987
Adtlress 3 East Ma-16"'
ain Street, wl g, Y 12564 LICense ao 61458 '
APPROVED FOR CONSTRUCTION Thii' approval °expues; two yea�s�ro`m the ate ued u ass construction of ^the building haf been" undertaken•-and iS
revocable for'.cause -.or may be art'endetl or, modified when cons�deJ necessary., y the`�Eom ;s' r fl, lth: •'.Any change 'or ralteration of construction
iepuires'a., now . permit." ApDlrove1 for disposal of domestic sandary; sewaq� 'and /or = vale wbter wpply ;only_.;
;Rev.���t� / `r �l''� Title
87
I
• .• P?PLICATICN FOR PUBLIC ACCESS TO R=COF.DS
TO FLCORDS A fC SS OFFICER DATE:
TI�:9M COUNTY
•nvi.ronmental
ll health S
Na. e o c _ tr - Bldg 3 JOSEPH L"� PSLOSO, J?t_ , PUBLIC
' 10512 - IN OR.r•zTION OrFIC?R
Address
I EFR, -= APPLY TO !NtPICT THE FOLLO:•' l `IG RECORD:
• cc k
r
Dam°
�; °7reSc t:1ZC
Ja Va-,
2�
M=i li nc Add_es=
ONLY
APPROVED
D7-
.j7ED
Racora of LJ ^? C - ^- t_7? s acancV 1s LEca Cus cdi 2 1 Cc_ ^_I10� �)e fOL';?C.
Record is not raintai *ied by t".---;s Acency
NOT7C7:
Ti tl o
YOU r.AT7— A RTG T TO Pte= I= L A DLN7A Cr T IS APPLIC ATION TO T
Name Business
-0 D =, F "uLT V LX?7;?.`I F�IS F.= ?_S,?i5 FAR SiJCii D- `I = ?.:, IV tv_ ITI:iG S V=II D:.'_'S
Os FZ,CFI?T- 0= P_I P?PFAL_
E!caatu_e
Ea to
e
r
O purn AM COMM
INE
DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL SITE INSPECTION
FIELD---INSP CTION RT
f )0--',::2t 1, 1 C� ( r_
Street Locatio
I YES I NO
Wetlands oh /or proximate to property ..............
Property lines or corners found ...................
Can estimate house location... ....................
Will driveway need cut... ................. o ........
Must trees be removed - note these ................ .
Deep holes representative of entire SDS area......
Additional deep holes needed..... ..... ....
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells/ septics ............................
D. H. 1 Lot
Depth to G.W. -- ---`T
Depth to rock
Soil Descri tion
0 ft.
3 ft.
t ft. G
9 ft.
12 ft.l . I
D. H. 2 Lot
Depth to G. W.
Depth to rock
—
0 ft.
3 ft.
6 ft.
Zf 't -
12 ft.
Soil Description
c
ti,
S
DATE:
INSP. BY•
COMMENTS
D. H. - Deep Hole
G.W. - Groundwater
D. H. 3 Lot
Depth to G. W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
5011
r—
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Room allowed for expansion trenches ..............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded.......... ..... ........
10 ft. maintained from property line and
20 ft. fran house ................:.............
Distance well to SSDS (ft.)., ............ o .......
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench.. ............
L5 ft. of peripheral soil horizontally
from trench ..... ...............................
Boxes properly set......... .<......... ........
:ould surface runoff from driveway, roads,
ground surface, etc., channel near SDS area....
does lot drainage appear OK in area of SDS.......
?INAL GRADNG OF SITE 'ACCEPTABLE ..................
DESIGN DATA; 'S
Owner
Located at (S
Municipality
PURgAm COUNTY DEPARMMU OF HEALTH
DIVISION.OF ENVIRONMENTAL HEALTH SERVICES
RMUFACE S&gAGE DISPOSAL SYSTEM - __... .. FILE IAA:
I Address
e Sec. Block Lot
- (indicate nearest cross street)
Watershed
SOIL PERCOLATION TEST DATA RDQU= TO BE SUBMI= WITH APPLICATIONS
6 1z
Date of Pre - Soaking' U Date of Percolation Test
HOLE
N[ZMM CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water From Water Level
No. Time Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop In Min/In Drop
4
K
4
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submitted
for review.
2. Depth measurements to be made from top of hole. /
rev. 9/85
ii
0
LAI
r"MH LA
LAT
MK
o�
�I
e
AS —BUILT DIMENSION TABLE
FROM — TO DIMENSION
A -- 1 18' -0"
B — 1 40' -6"
A— 2
B — 2 .
A — 3
B — 3_.
A -4'
B — 4
A — 5
B — 5
A — 6
13.7 6
A..— 7
B —.7
A - 8.
A - 9
B —.9.
A 10
B — 10
A —' 11
B — 11
A - 12
B — 12
A — 13
B -13.
A — 14
B —.14
A 15
B — 15
16' -0"
311-0".
17' -0"
26' -0"
22' -0"
25' -0"
25' -6"
22' -6"
..29' -6"
21' --6"
34' -0"
221-011
39' =6"
25' -0"
69' -0"
65' -0"
77' -6'!
75' -0"
76'. -6"
76' -0"
75' -0"
74' -6"
77' -0"
72' -0"
77' -0"
66' -6"
73' -0"
DESCRIPTION
HOUSE
CORNER
(SOUTH)
*TO
SEPTIC TANK IN-
SPECTION COVER
HOUSE
CURNER'
(NORTH)
TO
SEPTIC TANK IN-
SPECTION COVER
HOUSE
CORNER
'(SOUTH)
TO
DROP MANHOLE #1
HOUSE
CORNER
(NORTH)
TO
DROP MANHOLE #1
_
HOUSE
CORNER
(SOUTH)
TO
DROP- MANHOLE #2
HOUSE
CORNER
:(NORTH:)
TO
DROP MANHOLE #2
HOUSE
CORNER
(SO.UTH)
TO
DROP MANHOLE #3
HOUSE
CORNER
(NORTH)'
-TO
DROP` MANHOLE #3
HOUSE
CORNER
(SOUTH.)
TO'
DROP MANHOLE #4
HOUSE
CORNER.(NORTHI
TO
DROP MANHOLE #4
HOUSE
CORNEk:
(SOUTH).
TO
DROP MANHOLE #5
HOUSE
CORNER
(NORTH)
TO
DROP MANHOLE, #5
HOUSE
CORNER
(SOUTH)
TO
DROP MANHOLE` #61,
HOUSE
_CORNER
„ (NORTH)
TO-DROP
MANHOLE #6.
,
HOUSE
CORNER
(SOUTH)
TO
DROP MANHOLE #7
HOUSE
CORNER
(NORTH)
TO
DROP. MAN HOLE; #7 ,
HOUSE
CORNER
(SOUTH)
TO
7TH LATERAL END
CAP
HOUSE
CORNER
(NORTH)
TO
7TH LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO
6TH LATERAL END
CAP
HOUSE
CORNER
(NORTH)
TO
6TH' LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO
5TH LATERAL END
CAP
HOUSE
CORNER
(NORTH)
TO
5TH LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO
4TH LATERAL END
CAP
HOUSE
CORNER
(NORTH).
TO
4TH LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO.
3RD LATERAL END
CAP
HOUSE
CORNER
(NORTH)
TO
3RD LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO
2ND LATERAL END
CAP
HOUSE
*CORNER.
(:NORTH)
TO
2ND .LATERAL END
CAP
HOUSE
CORNER
(SOUTH)
TO
1ST LATERAL END
CAP
HOUSE
CORNER'(NORTH)
TO
1ST LATERAL END
CAP
ol
V
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