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BOX 12
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01246
PUTNAM COUNTY DEPARTMENT OF HEALTH
/- 0 r
DIVISION. OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
,,-,
dress Z)T&jv
Owner Ad
Located at (Street) g,4Vj4-,9Nn 7-32 Tax Map- .-;---Q---.- Block, 6 -V Lot V-/
(indicate nearest cross street)
Municipality 7:=,• 7-TE rzsg;,nz Watershed 15 vsr -A nAty
SOIL PERCOLATION TEST DATA
Date of Pre - soaking 6,12 Date of Percolation Test 12 ald/
I- - .. - . I
2
3
4
5 -- ---- --
3
4
5
NOT—ES-.— 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 for 1-30 min/inch, --q 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-97
e 'th toi-TA
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Start too.
. .........
-fic :
2
/- ------ --
4
2
3
4
5 -- ---- --
3
4
5
NOT—ES-.— 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 for 1-30 min/inch, --q 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-97
i
Indicate level at which groundwater is encountered -
- - - - -- - - -- ._«. -- - —
Indicate level.at which.mottling is observed--- __iy ®�
Indicate level to which water level rises after being encountered -- - -� - -� � -- - - - - - - --
Deep hole observations made by: ��� ', e ,, 12o, Date
Design Professional Name:
Address:
Signature:-
Design Professional's Seal -
TEST PIT DATA 2
DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES
DEPTH
HOLE N0. HOLE NO. BOLE N0.
_ G.L.
0.5'
�i^ace Ts,
iracc 7:
1.0'
2.0'
2.5'
3.0'
3.5' r .
4:0
ra,an W9 >J?
4.5'
_._.. .
5.0'
av s
5.5'
_ .. .
6.0'
. 6.5'
tie
7.5'
.8.0'
-
8.5'
-- ------- - - - - --
10.0'
Indicate level at which groundwater is encountered -
- - - - -- - - -- ._«. -- - —
Indicate level.at which.mottling is observed--- __iy ®�
Indicate level to which water level rises after being encountered -- - -� - -� � -- - - - - - - --
Deep hole observations made by: ��� ', e ,, 12o, Date
Design Professional Name:
Address:
Signature:-
Design Professional's Seal -
��JTNAIVI -COUNTY ]APARTMENT OF HEALTH
:. [Sd- FN'VIOME I�'I'�iL 'I�EAL,T�I[ SERVICES
INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM
SECTION A. GENERAL INFORMATION
Name, of Project 7>e7Z _1 ((1)N' 1 'Px7 -x6 ew County y i >yWN
Site Location A�gn 17'o�v _2:57Z,! a- S - 1 G mT S
Building construction begun ,No Extent "r--
Is property within NYC Watershed ? ................. Yes ❑ No
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑ Hilly D Rolling Steep slope �ntle slope F1at .
2. ❑ Ev' ence of wetlands �ow area subject to flooding ❑Bodies of water
Drainage Vie° : ❑ Rock outcrops
3. Property lines or corners evident ........:..::. Ye o
7�1T'�T•� ST..... Yes No
4. Do water courses exist on or adjoin the property? .......... _ � .
5. Will these affect the design of the sewage system facilities ?............ Yes ❑ No
6. Do watershed regulations apply in this development ? ....................... Yes ❑ No
7 Will extensive grading be necessary?.....`........... r ....... . __...... -Yes... ... __. _...:.;.:....__
8. Will extensive fill be necessary for SSTS? ........: ............................... ❑ Yes No
9. Do filled areas exist within the SSTS area ? .........................s ❑ No
If yes, what is the condition of the fill? ZEN TITt 4_ L-e --
SECTION -C. SOIL OBSERVATION
10. Appearance of soil: and ffGravel. ❑ Loam Clay ❑ Hardpan ❑ Mixture
11. Observed from: D Borings ❑ Bank cut �Backhoe excavations
12. Soil borings /excavations observed by 5.. 2O E p `h, G , , I�ff on 2 f° 10/
13. Depth to groundwater '' on
14. Depth to mottling ^1 o.OV 6 Ao c/AI Z> on
15. Are test holes representative of primary & reserve areas ....... .......................... No
16. Soil percolation tests made by go cam' o on
17. Soil percolation tests witnessed by 2r 1�- . G f'17 ,_ on
SECTION D (on back)
Form ST -1
- I
SECTION D. DRAINAGE
18. Will proposed grading materially alter the natural drainage in this or adjacent areas? 0 Ye EK
19. Will groundwater or surface drainage require. special consideration? ..................... Yes ❑ No .
20. Will gullies, ditches, etc., be filled and watercourses be relocated ? .......................... ? ❑ Yes [__J No
SECTION E. REMARKS
21. • If a common water supply is proposed, has an inspection been made of the
existing or proposed source and facilities? ................................ ............................... F_� Yes 12VII0
Inspection data
22. Do adjacent wells and/or sewage systems exist ?........:. AT.?/.al..q ............... Yes No -
23. Additional comments
24. Site, observer /inspector and title 4;,
25. Date(s) of observation(s)inspection(s)
TEST PIT PROFILES
Hole # Lot # Hole. #. Lot # . Hole # Lot #
Depth to water Depth to water Depth to water
- Depth to i'tliiirig '._ "` - Depth to mottling Depth to mottling
Depth to rocklimp.
Depth to rock/imp.
Depth to rock/imp.
G.L.
G.L.
G.L..
a _
0.5
0.5
-
1.0 _. - -
1.0
2.0
2.0. '
2.0
3.0
3.0
3.0
4.0
4.0
4.0
5.0
5.0
5.0
6.0
6.0
6.0
7.0
7.0
7.0
8.0
8.0
8.0
9.0 ''
9.0
9.0
10.0
10.0 __. _...
10.0
05/17/01 19:45
170-.. , �
PW SCOTT 4 2787921
,.._hRUCE R. FOLEX
Public Health Director
,1
d. EP R b WN d OF HEALTH
TH
1 Geneva Road
Brewster, New York 10509
ATTENTION: o A! DAM ST IEBELING )t GENE REED
NO.003 PO4
'S
LORETTA MOLIWARI R.N., M.S.N.
A nociete Public Mattlih Director
Director of Patient Sarvicet
M information below must be Lu& completed prior to any scbedWing, DATE: 51/4 of
ENGINEER OR FIRM: J W. 54011 PHOn Ai Ir 6111®
181£A$ON:
I BEEPS: Ja PERCS:.8 PUMP `PEST: 0
ROADISTREET: 1'tr? DJU Ue
TOWN: TAX MAPM: — !o -- A
SUBDIVISION: - A;
OWNER: Jose ?lJ - P &r&
y'a . ' K a �; `. . : 1, i`►1 ji►
YES
0 Proposed S. T'S within the drainage basin of West 13ra nch or Eoyds Corner Reservoirs..
o Proposed S 3TS_withiaa 500 feet of a reservoir, reservoir stmt or control. take.
Q - - Proposed MTS within 200-feee
0 Proposed S3T'S design flow greater than 1000 gallons/day or SPDES Permit required.
0 a� Proposed S3TS for a Commerical Project.
1t 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 answercJ;a to any of the questions, NYCDEP crust witness the soil testing. This
Department will coordinai e a mutually suitable time for Meld testing with the PCDOH, the Design
Professional and NYCDEF-
If a project has been dete -mined 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 a) schedule re- witnessing of the soil testing with KYCDEP,
FOR COUNTY USE ONLY
DATE. S i �� TIME: C9 /2 . zk2 ®I
(FMLOTEST)
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