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HomeMy WebLinkAbout1329DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.77 -1 -13 BOX 12 01329 PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. 3186 Division of Environmental Health Services, Carmel, N.Y. 10512 I j Engineer Mast Provide 1 Ihht� j P 8 l P.C.H.D. Permit N -- 52 Located ,ATE OF CONST Hazel Driv NCE FOR SEWAGE DISP SYSTEM Patterson Town or Village Tax Map 66 Block 1 Lot 4,5,6 Owner /appllc Name Herbert & PaTP -1a amissm Formerly. Raop/HaZPI Subdivision Name N/A Subdv. Lot I! Mailing Address 61 , Hazel Drive zip Date Permit Issued 5/23/86 Patterson, NY 12563 Separate Sewerage System built by Rr i an n l r'nnnnr Address Carmel, NY Consisting of . ' 11000 Gallon Septic Tank and 300 l . f . 61 curtain drain and.11 fill. Water Supply: Public Supply From Address or; X Private Supply Drilled by" Beal Address Brewster. NY Building Type Single Family Has Erosion CQdiY•o Number of Bedrooms 3 Has Garbage'6 *r JIer,Been Ineed�!' t� A; BAR Other Requirements I certify hat the a stem(s). as listed serving the above r r 'in ',, ro 1t3 , y y g p emi� 3:bere cd'n�truc�e`'d esaertCYa31y as shown t� plane ;I 1 lets (copies of which are attached), and in accordance with the etandarda rules and r[3yu1a81�ris, 1p acCDidance with f led a perm sued by the Putnam County Department Of Health. J �, une 1988 Oats ;. � ° 379:d urB&G; R06, Rte.21,!R,.JtraBs' ?ak, Brewster Ad ' Any person occupying premises served by the above system(s). shall pr wc�:actbn as may be necessary to qC rr of any unsanitary conditions' resulting from such usage. Approval. of. the separate sewerage syitem shall become null and void as an as "pu sanitary sewer becomes avallable and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are r subject to modification or change when, in the Judgment of the Commissioner of Health, such revocation, modification or change Is necessary. 1 Date / � ey� —� Title PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PQ 0v a -7a Owner or Purchaser of Building Building Constructed by 6 / 1-Eu zel �►-� ve Location - Street Pa 1-PeY5-�i Municipality /n f� 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, wor)ananship, 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 it mediately following the date of approval of the "Certificate of Construction Compliance ". for. the sewage disposal system, or any repairs niade'by':ine to sudi 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 detemination 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 the building utilizing the system° p p� Dated this day of 19 Signature Title General Contractor ( Owner) - Signature c/70►j/j 0 z co JS 4 Co Corporation Name (if Corp.) Corporation Name.(if Corp.) Address rev. 9/85 mk �v c 2 Address BREWSTER LABORATORIES Box 224 - BREWSTER, N.Y. (914) 225 -2072 - WATER ANALYSIS REPORT - SAMPLE NO. 6970 SOURCE: H. Jamison hose Bibb -well Hazel Drive Pu„nam Lake, NY COLLECTED: May 25 1988 BY: P.F.Beal & Sons, 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. May 27 1988 <� 6� Roy ai eao P.E. 1 � . Q �o /-1 .mr nmTnwr nr. nnnm W.GLL IJVl "ll LL 11 V1`I 1WLl Vitt Office Use Only j .e DEPARTMENT OF HEALTH Division Of Environmental Health Sery ices PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: 'MWN1V=1UUZ5IY TAX GRID NUMSU WELL LOCATION Hazel Drive, Patterson, N.Y. WELL OWNER NAME: ADDRESS. ❑ P6IVATE Herbert Jamison, 3135 Norfolk Rd., RD 3,Brewster,NY ❑ PUBLIC USE OF WELL 3 RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED 1- primary O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) 2 - secondary O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR ® NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 185 ft. STATIC WATER LEVEL _30 _ft. DATE MEASURED 12/3187 DRILLING If ROTARY I3 COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE . O SCREENED O OPEN END CASING, 49 OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH i - ft: MATERIALS: 12 STEEL O PLASTIC O OTHER CASING LENGTH.BELOW GRADE 100 ft JOINTS: O WELDED ® THREADED ❑ OTHER DIAMETER 6 in: SEAL: lJ CEMENT GROUT O BENTONITE ❑OTHER DETAILS WEIGHT PER FOOT 19 lb./ft. I DRIVE SHOE: O YES ONO I UNER: ❑ YES ONO SCREEN DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑ YES ONO ..DETAILS* SECOND HOURS GRAVEL PACK OYES GRAVEL DIAMETER TOP BOTTOM O NO SIZE: OF PACK in. DEPTH —ft. DEPTH tt. WELL YIELD TEST ' It detailed pumpingIELI. t LOG it more detailed formation descriptions or sieve analyses are available, please attach. METHOD: O PUMPED i tests were done is in- DEPTH FROM Water Well 19 COMPRESSED AIR , formation attached? ❑BAILED ❑OTHER I O YES ON SURFACE Bear- Inq Oia- meter FORtdAnON OESCRI?rtON G70E tt WELL DEPTH DURATION DRAWOOWN YIELD Surface b a IL hr. min. ft. 90m. it rock at 80' 185 6 165 30 80 101 Dftlling in rock set casing, route WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O No STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE submersible CAPACITY 7 g WELL OAIILfR NAME P.F. Beal & Sons , c . oATE- 611/88 . MAKER Gould DEPTH 160' AooREss PO Box B stcrntnin MOOEL7EH05412 VOLTAGk23Q_HPl/2 Brewster, NY 10509 APPLICATION FOR PUBLIC ACCESS TO RECORDS r TO: RECORDS ACCESS OFFICER DATE: January 26, 1988 PUTNAM COUNTY DEPT. OF HEALTH Name of Agency JOSEPH L. PELOSO, JR., PUBLIC INFOR "ATION OFFICER 110 Old Route 6 Address Carmel, New York 10512 I HER.:BY APPLY TO INSPECT THE FOLLO:•7ING RECORD: S1Sti'gt J. VEPREK "As- Built" drawings for well and septic on the following tax lot numbers: 66 -5 -1; 66- 1- (4'through 6); 66 -1 -3•; 66- 1- 2; -1 -1/j 66 -6 -1; 66 -6 -4. See attached Rider. ACKERMAN, ESQ. Representing 27.4 White .Plains Road Mailing Address Eastchester, New York 10707 FOR AGENCY USE ONLY Date APPROVED - _.. _...._• ..., _..._._ DENIED Record of which this agency is Legal Custodian cannot be found. Record is not maintaih!ed by this Agency Signature Title Date � NOTICE: YOU HAVE A RIGHT TO P_ _ -:_L A. DENIA., Or THIS APPLICATION LICA_ION t0 THE PUTNA;•1 COLNTY:•E: {ECUTIVE . Name 'Business Address WHO MUST FULLY EXPLAIN HIS F.= ?SO *iS FOR SUCH DLNIkT, IN WRITING SEVEN DAYS • OF R CEIPT• OF -PSI APPE,�:L. I HER BY APPEAL: Signature Date APPRIDER RIDER TO APPLICATION FOR PUBLIC ACCESS TO RECORDS TAX LOT NUMBER LAST KNOWN OWNER 66 -1 -1 :r,� Douglas Noah �. �,. 77 Hazel Drive, ,j Patterson, New York t �I 66 -1 °3 - Charles Eimicke 52 Hazel Drive Putnam Lake, New York 66 -5 -1 Uri''` Charles Eimicke 52 Hazel Drive Putnam Lake, New York 66 -6 -1. John Farrell 2217 Tanglewood Trail Virginia Beach, VA 23454 66 -6 -4 't;. a Po Higham 7 North Road f Brewster, New -York ... _... ..__.. . .._ __.. _. .. v. }r, 66 °1 (4 through 6) � �° �� R & R Dev ®lopiiieii�'Corpo Address unknown a i PUTNAMCOUNTY,DEPARIMENT OFHEALTH Division of Eavlronmenti Health Services Carmel N Y 10512 Engineerto Provide Permltq. TE OF COMPLIANCE f CONSTRUCTION P RMIT FO SEWAGE DISPOSAL SYSTEM ~ Peimlt .'q _ � i _Pat,terson Located at Hazel` Drive L ,Town or .VWago 4­5'.-E, _ Subdivision Name Sabd Lot q .Taz Mjj 6 Block 1 rat' 5, R l C it a n d R 8 p P Renewal'! ❑ Revision ❑ Owner /APpllcant Name c/o Scout Realty Dace et rso'n Previous; Approval Mallipg Address : Town Zip P =att(' Y Route" 6 & ,22', Brewster, New .Yo.ik 10'509 To le determined 3 x• 0 1:43 0: , Building Type ' Area - on, YOnl Deptb -" 'Volume'' `�Nnmber of Bedrooms 3 Design Flow G/#/D"­ 6 0 0 PCBD Notification Is Required When Fill Is completed Separate Sewerage System to consist of Gallon Septic Tank' sod To ,be contracted by _ a 0 b e d e t e r m i n e d'' 'Address` Waier'Sappl) Pabllc Supply -From Address or�X vate Supply Drilled by t o :b e d e OtherRegalrementa Al Of' �DO�( GU�TA 1� L`7�AlA�'. L,iepresent Chat.,l am ;wholly anon completely responsible for ;thedes,gnand location of ..the p►oposed systems) 1)`thatthe separate. sewage ::disposal, system, above des,ribed.will.be constructed as•shown on•tne approved amendment therelto and .nlc ordance with'the standards, rules an regulations o e Putnam . County Department':•of ifealtti `and that on'com Piet ion� thereof a'?ciirfificate;;of Construction Compliance" Sat isfactor"y'to the'Commissioner of Health will r•' be, supmdted:ao the Dapartinent; and ;a written- guarantee:wpU be .fuKnisped the,owner, hispsuccesso►s,.bevs or, assigns Dy'the builder, that said Duilder,wlll -a. place wn good.operaGng b_ondition y part of 'said sewage dfsposal•'`systarn, during the period of two, ,years immediately following the date of fhe Issu= once 'of the appr, val-oi the.tCertificatb•'of. Const�uct�on;Compliance of the o idal•sy,stem o►rany rapairs thereto;3) that tlie�drflled well described above. % will be lo4gted'as shown on the approved: plan'and'that'said well will' In •tall y ' accordance ,w{th, th i' sta ards r .tes and regu a Orrs of, the .Putnam: County Department of .Health. S J p� G� ' Signed P E R.A. bate r Cleanse No APPROVED FOR CONSTRUCTION -This approval expo_ 'cone year`iro her a Issued unless .construction 'of the :building has been undertaken acid. is revocable for c use or may be amended or';mbdtfied whe eider nece ry he ;l mmiss her of 'Health.. Any `change; or alteration _of construction reVUiies a ne , e Y sanit ryes a :and / r pr vat's ter suPPIY only: per i ° Approvetl fOr.dispbsal of ;ddm` s .! 1 Date .gy - Title _UUUIITY_UFFICi; 13U11,U111Ua CAlIh1LL,;: Na Yo 10512_. 0 fl)l:SlUli !>ATA Sl MU- SLl'/11U1TH SIN"JAUn 1]1SITS" SOT, N API LO, N 416!9961° - Richard Rapp Addi'eeu c/o Scout Bp-;31t,!4 Luuuted ob QStreet Hazel Drive Sego 66. 1310ok • 1 44 4. S.6;__..._..__ ��flic11C��® leeaa•ee� &'Cee � '8e ®�➢ . 1.1woLuipmILby' Patterson' Watershed SUIL 1'LMULATIU11 TEST Ld1TA 11LaUIMI) TO 131- SU131.111"1' WITH A1'1'L1C11'1'lU113 llule� ' 224 30 ' •21 23.5 2.5 12 11U1111101, CLUCK T11 -113 21 . ITIMOULATIU11 2.5 I'111CULt1'1'1UI1 NO 324 L71ap`je 21 wate1115Ve1 2.5 IWO* '1'11118 , 1'1'0111 urowid• Surllace 1.11 la thou Bull WIL- 1 St1�A -St01➢ 111980 Mart .. Drug JL19 1L19t°�111 drup ° C 1155 205 Incl9etl 119Cl9e1j 111c11ee 3.0 A 1153 209 16 21 24 3.0 5.3 2215 234 19 21 24 3.0 6.3 X236 253 17 21 24 3.0 5.7 ° 01253 312 19 21 21 3.0 6.3 B 1 154 ' 224 30 ' •21 23.5 2.5 12 2 221 254 30 21 . 23.5 2.5 12 254 324 30 21 23:5 2.5 12 ' C 1155 205 10 21 24 3.0 3.3 222.6 237 11 21 24 3.0 3.7 3 240. 253 13 21 24 3.0 4.3 . 11253 306 13 °: 21 21 3.0 4.3 ° olututo 9 1) '1'puty to be repeated at Uv.me depth THIN; I of v ►9'u 'l tilv%toA v o(III 1 D `' � 8 l • 1141LOO at'e Obtained ab eaulu poruplptf.09t teet pule. A�� da u to �u uu ,m1 ItIll .'rnoo: &'a8v OW. 2) . 13011t1a oueeeuremente tee be bade o•e l;UU111Y Ul�l�'1UL llUll.1)111U. Unluu�L;: il. Y. .LU,I�_ , llE31U11 VATA Ul -'1' -01-MA AUS W11AUH V1811USnL UYU'1'LI4 PILL IIU. U011u1' Richard Rapp /lddreee C/0 Scout Realty 1.vuulitliL at (l3l;ieeL. Hazel' Dr•ive"" ' - -- tleo. --66. Uluult 1 -� Xj; 4 `5 &;`6 `Yiiiali:aGe iii:�i•ngt viuee �I;i•e`eGj' i I-Iu1aa11 illy Patterson Witte relied BU1L 1'L ""IWULn'1'1U11 '1'1;3'1' DATA RE'�U1MS11 '1'U 1!L UU13I.111"1' 111'1'11 n1'11L1U/1'1'1U110 1111N llunilmm• ULUU1", '1'111.111 l'L11UU1l1'1'1U11 1'LIII;ULl TIUll Man _ _ 1?,lul,11a _ Uvl,l;li Cu N ►il;ea• _ _ _ _ �JaLer lc ►vel flu, '1'.Lu1e 114.0111 01-mid, 81111aae 1.11 1.1 ,,lieu UuI l WIL(► Uturt -ULuh 1•111u. U -91.1; UL•0II► Drop 111 6U.u. /111 drul► lttcllee 1uc;11en 111c11ou D 1 155 210 15 21. 24 3.0 3.0 216 230 14 21 24 3.0 4.7 •�� 332 244. 12 21 24 3.0• 4.0 E 1 157 227 30 '-21• 22.75 1.75 17.1 P. 227 257 30 21 22.25 1.25 24 ».` 257 327 30 21 22.5 1.5 20 Ilulwil 1) '1•mIL.M 1;11 by reppated al: "pis lept11 u111;11 ►J �1�1'u1!n�•1II•c►ly 111I11`11 � �Ill 1*111ea a1'e Ubl;allled at eaull IM1,uvlatlUU Net pule. n%�. aul,« to Vu ti111�1111�.�,u�1 .-1,U1, rev ea. 2) Impth meaguremeute to be n►ade 1'row tuh ul' Hula. •I �I of. f". 0 . .r, DEPTH G. L. 6" • 12" 18" 24" ,On J 3611 4211 4811 54" 6o" 66" 72" ;k 78" 64" S'EST PIT DATA REQUIMID TO LSE 'SUS1•S1TTrD 1, ITt1 APPLICATIOI1 DEtiCRIP`l'IOIt OP' SOI " %t17CGL'I ?i'F0RED II1 "i'1;,3T HOI,EZ IdOLE 140:. D -1 HOLE 110. D -2 ' . HOLE 140. D -3 Topsoil. , ....:... Topsoil:-- Topsoil ......_ ._... Topsoil Topsoil Loam Topsoil Sandy Clayey Loam Loam Topsoil Sandy_Loam Sandy cl aypy T.oam Sandy Loam Sandy Loam Sandy Loam Sandy Clayey ,Loam Loam Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sande Loam .. 2 @ Sandy Loam Sandy Loam INDICATE LEVEL AT 111LIC11 GROUND WATER IS ENCOUNTERED INDICA'T'E LEVEL TO WIUCH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS 14ADE BY Lawrence LePere Date G Soil Rate Used % Min/1 "Drops S.D. Usable Area Provided 300 L�=. 11o. of 'Bedrooms Bedrooms Septic Tank Capacity Gals. ' Absorption Area rov. a By � ` a6L.F'.x24'! fib" i. Co - f i P D6 f� 27- ��.cyt�S;x,YL Jji_ J � • T11IS ;SPACE FOR USE BY H1=TH DEPARTMENT ONLY: i Soil -Rate Approved Sq. Ft/Gal. Checked by Date C G,,� t L 4� J by • •. •. t! • a %j, . 00 or e, a C I C3 e . ' a Q Qom-"- -�,.,_ ' • ^ • .. •/ PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services APPENDIX L AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERH IT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health i In the matter of application for:' represent that I am an officer to act for employee of the corporation and am authorized . (Namef of Corporatiofd) having offices at Whose officers are: +. President: ( 04i Name nd Address) Vice - President:- Secretary: cr Treasurer: (Name and Address) m%e// and Address) t\ _ (NqWe and Address) / and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and_ all subsequent t. relating thereto. Sworn to before me this day Signed. of 19� Title: - 4: S 051 Notary Putt 'c BETTY L. EESPOSITO v Notary Public, State of New York No. 45:5303 Qualified in Pumam County AY Commission Upires Ap,N 30, 19 , 8/84 Corporate Seal (nT M COUNTY DEPARTMENrl OF HEALTH - DIVISION OF ENVIRONMaqTAL HEALTH SERVICES r� INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS i / REVIEW SHEET - CONSTRUCTION PMWT - DATE REYIEWED: +VC. BYS... (Name of Owner) (Street Location') rri�• 0 �0 vs 0� DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet.(DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request RDQUIRED 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 - Sizeo 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 & Expansion Area Expansion Area;shown; gravity flow,suff. size ° If Pumped Pit &'D Box Shown & Detailed House, - -Noo of Bedrooms _ ._.._....._.__.. Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft° 4 "0g Type pipe No Bends; Max Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Q.o Fields ° 10' to P °L., Driveway, Large Trees �• 20' to Foundation Walls " 100' to Well; 200' in D.L °0 °D, 150' pits 1001 to Stream, Watercourse, Lake.(inc. expan) 15' to Drains- Cartain,Storm,LeadereFoot -ing 25' to Catch Basin ' 10' to Water Line (pits -201) Septic Tanks 10' f ream Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D)�f: Data On DDS Plans ,& Permit Same / 11 11 h h DI• I• M ^i� I !! / REVIEW SHEET - CONSTRUCTION PERMIT IDh 61_ 14 sLy. Mel y� _ BY:: . 71b., --- Name of Owner) _ _ (Street Location) DOCUMENTS Permit Application iCorporate = Resolution Plans Three ;sets- -� Engi s Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole d Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED 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 & Expansion Area' Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House = No. of Bedroans _ Wells & SSDS's w/in 200 ft. of Propeity Located . Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "O;'Type pipe No Beads; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 410' to P.L., Driveway,. Large Trees C 20' to Foundation Walls 0 100; to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 151 to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin ° 10' to Water Line (pits -20.1) Septic Tanks 10' from Foundation ,. 50' to Well 15' Well to PL ORAL • Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same PLUNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES c., 6 INDIVIDUAL VQMM SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS FMD INSPECTION REPORT DATE 3 Pp o � G �. ►�'�t V t L- INSP. BY: _ (Name of Owner) (Street Location) ' INITIAL SITE INSPECTION YES NO COMMENTS Wetlands on /or proximate to property .............. On Property lines or corners found .................. Can estimate house location ........................ Willdriveway need cut ............................ 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... Q Adjacent wells /septics ............................. ACCPSS to nrnnnsed well location for .drillina..... F3' D.H. 1 Lot Depth to G.W. — Depth to rock — Soil Descri 0 ft. 3 ft. 6 ft. t 9 ft 12 ft. D.H. 2 Lot Depth to G.W. Depth to rock Soil Descriptio 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. 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. Soil Description Me So n 3r 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......... Roan 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.) ...................... Numberof bedrooms checks.... .................... Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench ................ 15 ft: of peripheral soil horizontally from trench ..... ............................... Boxes properly set ...a ........................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE.. 7d r Pd�,gm cOUNTY DEPAE"Ilma OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL M%M SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS _ .. _ ..... . -FIELD INSPECTION' REPORT .. - DATE: INSP. BY: (NSme of Owner) (Street Location) . INITIAL SITE INSPECTION I YES J NJ MV2, ENTS' U Wetlands on /or proximate to property .............. Property lines or corners found... ................. Can estimate house location ........................ Will driveway need dut ............................. 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 .. ... .... Arrr-ACC to nrnmcatl wal 1 1 nratinn for drillina..... D. H. 1 Lot Depth to G. W. Depth to rock Soil Descri ti 0 ft. 3 ft. o 6-ft. - D. H. 2 Lot Depth to G. W. Depth to rock Soil Descriptio., 7 0 ft. 3 ft. 6 ft. 9 ft: 9 ft. 12 "f t: Del U (- u. ti. - ueep riole jj G.W.- Grgundwater H. 3 Lot Depth to G.W. Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. 5011 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. fran watercourse .................... Natural soil not stripped or SDS area unnecessarly graded............................. 10 ft. maintained fran property line and 20 ft. fran house... ........................ Distance well to SSDS (ft.) ...................... Number of bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater, than 15 ft. fran nearest trench ................ is ft. of peripheral soil - horizontally frantrench .............3...... ............... Boxes properly, set................................ Could surface runoff.fran driveway, roads, ground surface,'etc.,: "channel' °near SDS area.... Does lot drainage appear .OK in area: -d:? SDS....... FINAL GRADNG. OF. SITE ACCETP,HI,E .F .. -r - (Name of Owner) COMKRM ee Loca ion YES NO DOCUMENTS Permit Application �rporate Resolution Plans - Three sets g veers AutYiot 0'10 Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Huse PlarisZao s s If M - Letter Variance Request REQUIRED 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 Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Rep ese tatve of S e & • <Expasi Expansion Area;shown;gravity _ flow,suff. size'--- Yf lhimpecl Pit & D Box Shown . & Detailed House - No. of Bedrocros Wells & SSDS's Win 200 ft. of Property Located /Property Metes & Bounds .House Setback Necessar -y (Tight lot) House_ Sewer l /4 " /ft 4 "0, Type pipe No Bends; Max. Bends 45° W /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. expan). 15' to Drains- Curtain,Stozm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' 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 CUNIT UFFICL 13U1LU11IU, U/►I9Eb;: If. Y. 10512 Lls'S1U11 011'1'11 SI r E'1' -S -1'/11111'1'1S SL'W/1U1S ]DISPOSAL SYS'1'1 M Vito. IIU: UWI1011 Richard - Rapp:- Address. c/o S _o u RF*al tv. -- 1,U0uLud ELL (8E1,eeL Hazel Drive sea. 66 Muck • 1 1,ut kidiumue tiearout; croue iiUFeeG')' 1-1wLic1J>3-11Ly Patterson' Watetulted SU1L' 1'LIICULl TIU11 TEST Lil1TA MQUIMI) TO BE SU131,111"1' 1WIT11 A1'1'L1CATIUll_3 llulu 253 17 21 24 llum1101, ULUCK TII,U� P EIICULATIUll 312 1211CULl1'1'lU11 (lint L Ntli-UU W5M WraEU Level 6.3 11U. '1'11119 h`roul Urowd• Surface III 11 4r:I1e1 Bull WiLu SLarL -Stop IIJ u. gLarL stc t llrUp 111 Id1n. /lu drup •21 23.5 Inches 1110 {feu 111011©1 2 221 A 1153 209 16 21. 24 3.0 5.3 2215 234 19 21 24 3.0 6.3 236 253 17 21 24 3.0 5.7 ti 253 312 19 21 21 3.0 6.3 1 ' B 1 154 224. 30 •21 23.5 2.5 12 2 221 254 30 21 23.5 2.5 12 254 324 1 30 21 23.5 2.5 12 it C 1155 205 10 21 24 3.0 3.3 2226 237 11 21 24 3.0 3.7 3240 253 13 21 24 3.0 4.3 11253 306 13 21 21 3.0 4.3 IIULU'l1 1) Tvat -9 to be repeated at 1n.111e OevMI witli o 11ru� u►�I;c1v ©111` i 1� I l 111189 ure obtained aL each peroplgLiou tout Rule. A du u Lu bu tiuiiul t,�,u�l . •ful• rev eW. 2) Wptlt meauuremeutu to be blade from top of hole. �r i . _ _ ' CUUII1'Y U1i1r1CL 13U1M111% UAITILl+➢: H. Y. 10512 DESlU11 DATA Sl MT -S E1'/11I11'O SEVAUH 9151105/18.0 SYS'b&I FILE IWO - - :.Vaolonm Richard ... Rapp . �1dda'eee c /cf - Sa .,t- -Real t-u-- l,UC:uted UL (Street Hazel Drive sea. 66 Ploult • 1 Vert 6 •_ - - -_. ��iii�l��t® 0aie�g'v�C �s'oee �Ca' ® ®G - ➢• '. i flaiLlclgallty, Patterson' Watershed BUlb 1'LIIUULd1'1'1U31 T EST DATA IMUIRED '1'U 13H SUBMIT= 1.11'1'18 /II' UC11'1'1U11;.3 llulc� . IIw111101° MUCK TINS, 1'LIICULATIU11 12IiCULATIU11 11WA F;I pia D'eptla to Wel;e1° Water Level 11u. '1'11110 Urow0d• Surrace iII to lieu bv1.1 1111tu d31;aa't -Stogy 1.8110. Start M. Dg'ol� I0 1.8110./111 di I10claee 11acl0ve 1uc,livr� A 1153 209 16 21 24 3.0 5.3 2215 234 19 21 24 3.0 6.3 236 2 5 3 17 21 24 3.0 5.7 ° 11253 312 19 21 21 3.0 6.3 ob B x 154 224 30 ' •21 23.5 2.5 12 2 221 254 30 21 23.5 2.5 12 254 324 30 21 23.5 2.5 12 1 C 1155 205 10 21 24 3.0 3.3 2226 237 11 21 24 3.0 3.7 3240 253 13 21 24 3.0 4.3 11253 306 13 21 21 3.0 4.3 Ilcal;e�11 1) Test -a bu be repeated at 09.111® depth uIlUl F) 1o,�a1�1n11'ely e(111�11 alines ure obtained at each Peg'eplpitio00 te0t hole. AYI da u Lu Lv vu 91111, ui . A'oda a•ev era. 2) BJepUa measureme00to to be node from togs of hole. �J J.. J. J6 V.. VA "... /... v.•• .•..•.. CUU111'Y UFFICS BU1Lll111U. UAIT .: 11. Y. 1U512_ VESIU11 VATA 131 r S'1' -S rI'/11U1'1'1S SEVAUS ll1SPOSAb SYS'1'EN 1r1LS 11U. :.._ _UW�tol! _.. Richard-Rapp - - - C /0._ -S/Oz Rea.ltu Lucuted at (8i feet Hazel Drive geo. 66 1llook • 1 1,ut 41 5 & _6 �liiillcaGe iegi'v�G`ai�oss �Ci�e "eG)• , . i flwdulpaliby Patterson Watershed BUM 1'EIICULII'1'1U11 TEST V1 TA REQUIRED '1'U llH •SU131,111"1' WITH AITL1Cl1'1'1U113 lluly 155 . JlU11111 1. ULUCK '1'1111; I'EJICULII'1'1U11 ISMULII'1'1U11 11WI 11; ta —Ppe VOPWI`to`Watell 11 Ceti 1�vve "1 flu. 7'.Lu1e Ii'rom Urowtd' Surface iii It rated Sol l' I1nLa t3tart -Stop 1'llu. Stgxt Stu t llrolr tt 1.LLtt. /lt1 dl-up 21 24 lushes 1ttc�tvs lttcltvn D 1 155 210 15 21. 24 3.0 3.0 2 •� 216 230 14 21 24 3.0 4.7 332 244 12 21 24 3.0 4.0 1 ' E 1 157 227 ITT 30 '•21• 22.75 1.75 17.1 2 227 257 30 '•21 22.25 1.25 24 257 327 30 21 22.5 1.5 20 1 2 Ilutc�t t 1) Tentg to be repeated at a6miv 4leptil uIlUl 1) 11 iI►tl ;elv oc ii`i t ' 0I ll rttlee are obtaltued at eaoll peroplgtloii test (role. A du�u to bo �ulnnl�•�,tf . -fur rev eN. 2) Wptli measurements to be made from top of hole. f Ilutc�t t 1) Tentg to be repeated at a6miv 4leptil uIlUl 1) 11 iI►tl ;elv oc ii`i t ' 0I ll rttlee are obtaltued at eaoll peroplgtloii test (role. A du�u to bo �ulnnl�•�,tf . -fur rev eN. 2) Wptli measurements to be made from top of hole. f 72" 7811 M I IRDICATE LEVEL AT 111FICII GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WIIICII WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY Lawrence LePere Date JDESIGN Soil Date Used 7 i` hVl "Drops So Do Usable Area Provided L r No. of Bedrooms 2 Septic Tank Capacity 10.Ci0 Gals. 'I' pe Absorption Area rov deT Bye .Fax24l' 7 wir O r` . CE me .1 Address THIS SPACE FOR USE BY I =11 Soil hate Approved Selo F't /Galo A L .1980 Nw-/?6-F,r. -S5v(007jr Checked by Date ®I ' TEST PIT DATA REWIRED TO BE •SIII't,ITTEM WITH APPL•ICATIO11 DE,,'C12IP'1'I011 OF' SOILS ,?N""OUPT RED II1 TEST 110LEE-3 DEPTII 11012 1406. D -1 .HOLE NO. D -2 ' . 110Lr 140, G. L. Topsoil .. Topsoil* 611• Topsoil Topsoil 12" Topsoil Sandy Clayey Loam 1811 Topsoil Sandy Clayey Loam 211" Sandy Loam Sandy _ ('16geg T.oam Sandy Loam Sandy Loam 36" Sandy Loam Sandy Loam 42" Sand Loam �:,. ; •:.,., tl a" 5111" 60" 66" 72" 7811 M I IRDICATE LEVEL AT 111FICII GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WIIICII WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY Lawrence LePere Date JDESIGN Soil Date Used 7 i` hVl "Drops So Do Usable Area Provided L r No. of Bedrooms 2 Septic Tank Capacity 10.Ci0 Gals. 'I' pe Absorption Area rov deT Bye .Fax24l' 7 wir O r` . CE me .1 Address THIS SPACE FOR USE BY I =11 Soil hate Approved Selo F't /Galo A L .1980 Nw-/?6-F,r. -S5v(007jr Checked by Date ®I TEST PIT DATA MQUIRED TO BE -SUPMI TED 1!1T1.1 APPL•ICATI011 DESCRIPTiOI1 OF' SOILS E11COlJPTERED II1 TEST HOLE? UEP II 11012 140:. D -1 11012, NO. D -2 ' . HOLE I40. G. L. Topsoil _.. ,_. .. Topsoil" 61'• Topsoil Topsoil 12" Topsoil Sandy Clayey Loam 1131 Topsoil Sandy Clayey Loam 211 Sandy Loam Sandy CI AUpy T.oam JO" Sandy Loam Sandy Loam 36" Sandy Loam Sand Loam 112" Sandv Loam 1i13�� 51111 60" 66" 72" 713 11 • EM IN'DICA'TE LEVEL AT WHICH GROUND WATER IS ENCOUNTERS INDICA`T'E LEVEL TO WILICH WATER LEVEL RISES AFTER BEINQ ENCOUNTERED TESTS 14ADE BY Lawrence LePere DESIGN Soil hate Used 7 Mir 1 "Dro : S.D. Usable Area Provided F. 11o. of Bedrooms Septic Tank Capacity 1000 Gals. 'Type Absorption Area rov etc Bye .F.x24" �"— width tylench. z" - Fly, ame Address ,,,,,.��, 0- n;Q F:C- THIS SPACE F'013 USE BY i =TIT DEPAR' MENT 'Soil Rate Approved Sq. Ft/Cal .' 't 1980 •"= ' TEST PIT DATA lil'(�OI1ED TO BE 'SU.M- ',1--'YI'ED LTITH AMICATIO11 ° - UESUR11 "1'IU11 Of" SOI " II•l• TE3T 110131 ° llEl''1'11 11JLE' 140e. D -1 110E uo .D -2 11Ui►>; I40. D -3 ° Topsa], ° To soil Topsoil Topsoil Loam • ° ° 12" To soil Sandy Clayey Loam T.oa m ° .1(3" Topsoil Sandy Clayey, Loam ° Loam _ 7 K O 211." Sandy T.oam ° Sandy CI PVP;j T oam Loam Sandy Loam ' ° y S nd T.onm Sand Loam ° Sand Loam Sand Loam Sandy Loam 112`' Sand Loam Sandy Loam 116 Gw ° 1 .�{-,, Sandy Loam 51111 _ ° Sandy Loam • 60,11 Sandy Loam ° .66 . ' Sandy Loam / .�2!1 6W @ 6 r Sandy Loam ° (3l1 0 ° Sandy Loam I11DiCATE 1, TVI,L Nf WHICH GROUND WATER IS +'NC000TEPED 3.111)1Cl1'I'C LLVf,L •'1'U WILUM WATER LEVEL RISES AFTER ©BEIIIG ENCOUHTEIiED _ TESTS 111WE •13Y `Lawrence` LePere llate Soil, Ae Used 7 11Lia/1'�llrops S° D UsaUle /tree 1 ,oviiled `- 11v. � < SOptic '1'ai11t Ca�L� city /�,, > Gals ° ' 'Type _ 'Ab.sorptioii Area �rovielec7 Bye F'ox2 #" s i,r- width trelic.11. Mier o l'lailie _/'C;� c:r:� -.,� l; r= e igtia 'ure a' u _t '1'111: •DD'/10E I Uli US ' LY )°11;11L'1'1i1' Soil Ita`t;e /1lapioved 'a �. 'hut /C 1 sGleckeci by �r� jite =� s. }` r t' , � r f`•' .mss _ o l '1 'M r ll�1''1'I I 6;1 1C3 ", 11211 'i'.vS`1-PIT DATA IIEQUIMM TO PE SUP-147 "YTED WI'fll ILPPLICf I'IUII -llL;SC11BIT Toil OF, SOIM i;'Nr"OuP'f1;B,ED II' TE31' 110LB -0 Sandy 11JLL 1�0:. D -1 I1013 ISO. D-2'*. 110LB. 140. D -3 T'ops.oil Topsoil' Loam Topsoil Topsoil Topsoil _ Loam Topsoil Sandy Clayey Loam T.Oam aTopsoil' Sandy Clayey Loam _ Loam San 'v .CT 0 o Loam Loam Sandy aTVr T.oam Aandy`Loam Sandy Loam Sandi Imam Sandy Loam, Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam. ,- 6W-@ 6' Sandy Loam Sandy Loam H1.1)iCATE LEVEL AT 1.1111Cll GPOUHD WATER IS MCOUNTE -R M 1.11DIGA'1.'E, LEIWEL TO W1ll.C11 WATER LEVEL RISES AFTER BEING EflCOUHT FRED _ TESTS AME 13Y Lawrence LePere Date LSIO 1.8. oil -slate -Used 1llir/1 Urop:....�. _. . - � S-.11. Usable Area Provided: 'llcr. of t "e(II'001113 Septic Tank Capacity Gals. '1'Ype ��soz ptioti Area �'rvv3deif By �_� L. F. x24" Y S"— widt reiic[i. " Other Li I Address l ?,i; SEAL ' rye TIF-[a SPACE 1;,oll USE LY IIEIWkjl DEFAR'1'1 MT ONLY: °B' 611 Bate Approved Sq. Ft/Gal. Checked by Date }. Cz 0 o ," ' rye }. 0 o 21111 J 14211 Il611 51111 6011 6611 (j11 11 ,Sandy Loam Sandy Loam Sandy Loam Sand}zCIa�zPV Loam Sandy Loam Loam ,1A I It Y 1'.cST PIT. DATA HEQUII E, D TO BE •3UF4-';1 TTED 1.11111 APPL•ICATIUI1 Loam DESC111I7 1, ON UP' II•I TE3'I' 11OLL'3 DE111,11 1 11J NO., D -1 HOLE NO.. D -2 ' . ° BOLE I10. D -3 Sandy Topsoil Topsoil Topsoil 6W @6 Topsoil Topsoil Loam 1211 Topsoil Sandy Clayey Loam I ,,Qa m _ 1811 Topsoil Sandy Clayey Loam Loam 21111 J 14211 Il611 51111 6011 6611 (j11 11 ,Sandy Loam Sandy Loam Sandy Loam Sand}zCIa�zPV Loam Sandy Loam Loam ,1A I It Y 1.0 YI III O Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sandy Loam Sander Loam 6W @6 Sandy Loam Sandy Loam I (IUI CATC, LEVEL AT WHICH GBOUND WATER IS ENCOUNTERED IND1CA'1'C LEVEL TO MUCH WATER LEVEL RISES AF'I'Efi BEING ENCOUNTERED ... TESTS I. WE 13Y Lawrence LePere Date EMO .._ Soil Ra' to Us-O T I hVi "Drop. S.D. Usable Area Provided 11o. of, I'nclrooms ? Septic Tank Capacity Gals, Type AbsorpLiou Ai-ea-1-TO-Vide-d' i;ea Provided• 13, L.F'ox2411 6 "� widtU eiich. OL-her Ilatne _/fir: i'!:�1. •_t_ i r= /:. rr iii aE'tu�e SEAL '1.1113 SPACE F•oll USL LAY I '1'Il DEPAR`1'I 11T ONLY. Boil RaLe Appi,oved Sq. Ft/Gal. Checked by Lute 0 } 0 c F i 0 } 0 c PE � �Q "ZI l?. lk 77' J Q� r G IC. >3fl 131✓ � GE, f5a , c E2, Department ux nealtk E,E2 nmental Health Servicen' for 'conformance with id ReFulations of the `h Department., 7z 15� Z7� 40 441 5d, 3z 47' 0F2 L �2 F F�, G!� bN C. N G I, �2 3z sz 55� 58 Coo (a5� (a(p' C-1z 1,12 8 J, $ Jz, cit. J,J' 5.7 32: 71� 1' 811 90' 3z �� TH►s IS To GEKTIF`( THA`r THE sEWaG,E D1SP0SAL SYST> =M Wt15 GOt,ISTPIIGTED....45 -. I WP V,dTED OIJ THIS THE w SYSTEM Wb,S IMeFELTED UNDER MY SUPEJZ- V IS l OAl 8E'FORE. IT' WAs LoVE.i•LE.D o VErL • TwE S`(S"rEM WAS GoNSTtLULTED iN b.LLOR�tS.FJLE W ITN ALL S- `ANi74fLD RULES V ��. 15 NJD 7- ECJUL- .&7 -16>ws of T1.1E Pu-rQA M �C"-YA 0 Gouuw �EP4fLTh�) ICJ C�wnY'- RTMI =-NT' 'a SEAL 'C' =co;, 1480 rP�� Bb.L.t7 W t�i �•' •.��.i.l� S �'. G . 5z5aa DATE: Su I L7 t ' JOB No. 762 10 t 1ibZ�L r✓R.WE PuYNt►M (.,J.KE ,. QWG. NQ, Pis.- rr�.r�sc�a Pu-r►.ta.t�1, C� o . • 1. 1 1 � G IC. >3fl 131✓ � GE, f5a , c E2, Department ux nealtk E,E2 nmental Health Servicen' for 'conformance with id ReFulations of the `h Department., 7z 15� Z7� 40 441 5d, 3z 47' 0F2 L �2 F F�, G!� bN C. N G I, �2 3z sz 55� 58 Coo (a5� (a(p' C-1z 1,12 8 J, $ Jz, cit. J,J' 5.7 32: 71� 1' 811 90' 3z �� TH►s IS To GEKTIF`( THA`r THE sEWaG,E D1SP0SAL SYST> =M Wt15 GOt,ISTPIIGTED....45 -. I WP V,dTED OIJ THIS THE w SYSTEM Wb,S IMeFELTED UNDER MY SUPEJZ- V IS l OAl 8E'FORE. IT' WAs LoVE.i•LE.D o VErL • TwE S`(S"rEM WAS GoNSTtLULTED iN b.LLOR�tS.FJLE W ITN ALL S- `ANi74fLD RULES V ��. 15 NJD 7- ECJUL- .&7 -16>ws of T1.1E Pu-rQA M �C"-YA 0 Gouuw �EP4fLTh�) ICJ C�wnY'- RTMI =-NT' 'a SEAL 'C' =co;, 1480 rP�� Bb.L.t7 W t�i �•' •.��.i.l� S �'. G . 5z5aa DATE: Su I L7 t ' JOB No. 762 10 t 1ibZ�L r✓R.WE PuYNt►M (.,J.KE ,. QWG. NQ, Pis.- rr�.r�sc�a Pu-r►.ta.t�1, C� o . •