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Home My WebLink About1514DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 34. -4 -7.2 BOX 14 . .. M. .. : �� I .: E . . 4 ;� � 1. .1 re 0 6 St. IS I. . �� I. nN IS r -� of 01514 PUTNAM COUNTY DEPARTMENT OF HEALTH r .-I DIVISION -OF ENtYIRONMENTAL HEALTH SERYICES- CERTIFICATE OF CONSTRUCTI01SLCOMMANeE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # ` "Alft Located at _:2�G e- °a ye 4,a-I Owner /Applicant Name 70�', Apse Formerly Mailing Address Tax Map 4Lot Subdivision Name Subd. Lot # .2- Date Construction Permit Issued by PCHD Separate Sewerage System built by /yfl't, v' W" c e Address ZipIQ S'v Consisting of JeveU Gallon Septic Tank and 5° Other Requirements: Water Supply: _ Public Supply From or: Private Supply Drilled by %3 e �ell /31w -ls Address Address 13,, vAO -4'' y Building Type Has "erosion - control been cornpl'eted? '" Number of Bedrooms Has garbage grinder been installed? 14110- I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: Certified by Address 2 97 �—' P.E. r°' R.A. # Sys Any person occupying premises served by the above syste ai'tmi ky ° e such action as may be necessary to secure the correction of any unsanitary conditions resulti `fir gib, us e. Approval of the separate sewage treatment system shall become null and void as soon as a pubh tats 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 ubject to modification or change when, in the judgment of the Public Health Director, such revocatio , o ification r change is necessary. By:. Title: L `U�' /�` Date: 'L White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 a • DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road. ,Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 August 20, 1998 Frank Sullivan, PE 2972 Ferncrest Drive Yorktown Heights NY 10598 Re: Proposed Compliance Hanson Ice Pond Road, Lot #2 (T) Southeast, TM# 34 -4 -7 Dear Mr. Sullivan: BRUCE R. FOLEY Public Health Director Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1) There is no record of a final inspection being requested or conducted by a representative of this Department. _.... 2) Letter of Authorization is to be fully completed (enclosed). Upon receipt of a submission, revised to reflect that above comments, this application will be considered further. Ve ly yours, Robert Morris, P.E. RM:tn Public Health Engineer enc. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Building Constructed by �2 /�l/A. el Location - Street Building Type Town/Village /`fZfVAs A -rie. Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that. is 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 treatment 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 the determination of the Public Health Director 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. Dated: Month % Day l Year 1 � Z-1 G/9 eral Contractpr (Owner) - Signature Corporation Name (if corporation) Signature: Title: Corporation Name (if corporation) Address: 2Z S . )Z/-/D &4 D PA-/76?,-5Address: State X/ % Zip /�T?7 - State Zip Form GS -97 Owner or Purchaser of Building Tax Map Block Lot: Building Constructed by �2 /�l/A. el Location - Street Building Type Town/Village /`fZfVAs A -rie. Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that. is 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 treatment 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 the determination of the Public Health Director 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. Dated: Month % Day l Year 1 � Z-1 G/9 eral Contractpr (Owner) - Signature Corporation Name (if corporation) Signature: Title: Corporation Name (if corporation) Address: 2Z S . )Z/-/D &4 D PA-/76?,-5Address: State X/ % Zip /�T?7 - State Zip Form GS -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH, SERVICES FINAL SITE INSPECTION /r Date: / Inspected by:� -� \ Street Location AT-, e 1:::'� 2 P Owner 50c-- Zr � Town � Permit # TM #— Subdivision Lot # 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/ wetlands ...... ............................... II. Sewage System. a. Septic tank size - 1,000 ......... 1, 250 .......... other ................ b. Septic tank installed level ...........:.... .................... ............ c. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - roperly set ....................... ............................... ength required Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... l Q. Pipe, ends capped...................... :...: ....:..:::.:.::::::.::.:::::::. g. Pump or Dosed Systems Size ot pump c am er ................ ............................... 2. Overflow tank ........:.................... ............................... 3. Alarm, visual/ audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. HouseBuildin a. House located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans ........................... b. Distance from STS area measured _�C�ft..... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 orm -3 T'achowledge receipt 6,-this report: ' SIGNATURE; W/96 Titled YML ENVIRONMENTAL SERVICES 321 Kear Street Yorhtown.Hei/gh�sv�N��{K�R��'�c�:��''s�'� (914) 245-2800. Albert H. Padovani, Director LAB #: 93.800932 CLIENT #: 9443 NON STAT PROC PAGE I HANSEN, JOHN ' DATE/TIME TAKEN: 07/28/98 11:30A P.O. BOX 503 DATE/TIME REC'D: 07/28/98 12:00P BREWSTER, NY 10509 REPORT DATE: 08/05/98 PHONE: (914)-279-8319 SAMPLING SITE: ICE POND RD SAMPLE TYPE..: POTABLE : PATTERSON ' PRESERVATIVES: NONE COL'D BY: JOHN HANSEN TEMPERATURE..: NOTES...: KITCHEN TAP COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL _ RANGE - METHOD ' PUTNAM CNTY PROFILE ` 07/28/98 MF-T. COLIFORM ' ABSENT /100 ML ABSENT 1008 07/28/98 LEAD (IMS) <1 ppb 0-15 ppb 12345 07/28/98 NITRATE NITROG ' 0.41 MG/L 0 - 10 9139 07/28/98 NITRITENITROG <0.010 MG/L N/A 9146 07/28/98 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 2037 07/28/98 MANGANESE (Mn) <0.01 MG/L 0-0.3 mg/l 2037 07/28/98 SOD}UM (Na) 6.92 MG/L . N/A ' 07/28/98 pH 7.4 UNITS 6.5-8.5 9043 07/28/98 HARDNESS,TOTAL' 114 MG/L N/A 07/28/98 ALKALINITY (AS 84.0 MG/L N/A I[)I]`Y-.(TU��'.- --'<1_N 0_5i]NIU_-. COMMENTS: BACT THESE RESULTS INDICATE THAT THE WA (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN�-��THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb /CU LEAD limits for pi EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. _tblic schools set at 15 ppb. Rule for Public Systems requires that no more distribution point---, have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is Suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street . .—Ypr ktawn (914) 245-2800 Albert H. Padovani, Director LAB #: 93.800932 CLIENT #: 9443 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ HANSEN, JOHN DATE/TIME TAKEN: 07/28/98 11:30A -P.O. BOX 503 DATE/TIME REC'D: 07/28/98 12:00P BREWSTER, NY 10506 REPORT DATE: 08/05/98 PHONE: (914)-279-8319' SAMPLING SITE: ICE POND RD- : PATTEFSU]N COL'D BY: JOHN HANSEN NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METH01) pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND-FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM - -CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L--` M M ILLI PER LITER ' ' R _- . --___--__'_'--_---- 300 MG/L (1 grain/gallon 17.2 MG/L) ' SUBMITTED BY: ;ZZ-f-H Fadovani, M.T. (ASCP) ` ELAP# 10323 PUTNIAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . WELL.00MPLETI<ONI REPORT Well Location Street Address: Ice Pond Road, Lot #2 Town/Village: Brewster Tax Grid # Map Block Lot(s) Well Owner: Name: Address: John Hansen P. 0. Box 503, Brewster, New York 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 31 ft. Length below grade 30 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded X Threaded _ Other Seal: X Cement grout Bentonite Other Drive shoe: X Yes No Liner: Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static specify ft) 100' During yield test(ft) 545' Depth of completed well in feet 585' Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 11- Drillin• in overburden clay and boulders 11-, Hit . roc at 11-11 12 31 Drillin irn rock set casin .._ routed 31 585 Drillinc in rock ciranite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed 12/7/95 Putnam County Certification No. 002 Date of Report 5/18/, 98: �. Wei 1 si Nui'i6: rxact location of weii win aistances to at least two permanent landmarxs to ne provVea on aseparate sneevpian. Well Driller's Nam 1 So s, Inc. Address: 4 Putnam Avenue, Brewster, NY Signature: Date: 5/18/98 Mal lm Beal, White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 P011UM COUNTY DEPARTMENT OF HSALTH DMdM d 8nvbs =aA.) Had & Savbbm Calfalel. N.Y. 10512 to FewMe Pasty N, . an CERTIFICATE OF 1MPU4NCE -�7 CO N PERMIT FOR SEWAGE DISPOSAL STR M Fame 0 Lomas d G �/ 0 G dam' '� ►^ or Nuhl , owe as 'vie jj Map Lot Y _ .r. Ter: glade at Otraae(AppNeW Nailing cJ f7 T✓ h /44 /% Ronowai_° Rm�isn ° Date of Prevbae Approval c� Mdftg Adda+e Town 1. _�ic°�yr�� ,�ir' zip. / y s' e. Date Subdivision Annroved If 's 9 Fee Enclosed Amn,mt c aG) Type ��' G S i G7�i12 Gr Lot Aron 2 f Ci �1 1-ii"PCHD Section Oolp Dop�b volume Ntanbee d Btidleom -3 Derip F)ow G P D 6 NotModen b. Regldmd Wbon FM b completed Separate Sewaase Sydm to CUMM d Aa O G tin Septic T.ok A 4 " To be amsbucad by d �✓ s!ir Addrew Water Strpor. PdAk suppb F Address are daft Sappb Deed by sddma odder I<eaodreaeeafa 2 f i? o 3 1r;_ /Z 1 represent that I am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate sew disposal system above described will be constructed as shown on the, approved amendment there to and in accords h the standards, rules a regu was o ream County Department of Neagh, and that on completion thereof a "Certificate of Construe ' " satisfactory to the Commissioner of Nealthwill be submitted to the Department, and a written guarantee will be furnished the owner assigns by the builder, that said builder will pace in good operating condition afiy part of Mid sawage disposal system during t s immediately following thedate of the issu- anq of the approval of the Certificate of Construction Compliance of the original any r s o: 2) that the drilled well described above will be located as shown on the approved plan and that said well will be Installed in a wit rules and r gu aZ o�i n�f the Putnam County Department of Health, _ Date /%/ � 7 .g �J Signed / P.E. _�+ R.A. Address G jJ %/ c /n GT�i°j /! m• ./w License No APPROVED FOR CONSTRUCTION: This approval expires two years from the dat iss d Wy of building has teen undertaken and is revocable for cause or may be amended or modified when considered necessary by the Co Any change or alteration of construction requires eve p it for disposal of domestic sanitary w y. Re V . 10/88 °a DEPARTMENT OF HEALTH' Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION `tO. CONSTRUCT X WATER WELL__ PCHD PERMIT # WELL LOCATION Street Address Town/Village/City Tax Grid Number WELL OWNER Name Mailing Address �� lr� '%✓� tf cr %i�w >11- rivate 0 Public USE OF WELL 1 - primary 2 - secondary *RESIDENTIAL ® BUSINESS ® INDUSTRIAL ® PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION b INSTITUTIONAL 0 STAND -BY 0 ABANDONED 0 OTHER (specify AMOUNT OF USE YIELD SOUGHT �� gpm /# 0 REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING PEOPLE SERVED - /EST. OF DAILY USAGE 600' gal [3 TEST/ OBSERVATION 12- ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL- REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED ® DRIVEN ®DUG ® GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓- NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ar wXJ Lot No. 2, WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY > DISTANCE- TO,PROPERTY FROM:- NEAREST WATER; MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (dat ) 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 thirt=y (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 Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the the Putnam County Health Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in su�ama er as not to degrade or otherwise contaminate urface or groundwater. Date of Issue: . �-% 9 Date of Expia it on C/ 19-!Z Permit Issuing Official Permit is•Non- Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH_SERVICE.S_ Date Re: Property of .5-0 mod' �r V Located at Section 3 Subdivision of Subdv. Lot # Filed MaA —r Block 4 Lot # 2Z" Date Gentlemen: l This letter is to authorize �S C p P// _0,�/ a duly licensed professional engineer d� or registered architect (Indicate .to apply for a Construction Permit for .a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to_ superv,s_e,_the_ construction of,,.sai.d system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Counteertsg nt�'d �✓L MON =_; /�f Telephone Very truly )roArs, Signed uwner or Property Address ^� Town Telephone PC -1 PUT NAM COUNTY D E PART M E NT OF H EA EY H APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: !JVA7 /t °41se�, 2. Name of Project: 3. Location T /V /C: 4. Project Engineer: G� /� �G� 5. Address: License Number: Phone: 6. Type of Project: private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? IV67 Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required ?' 9. Has DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency 11•.-Is thts••project,-in an area under the control of local planning, zoning, or other officials, ordinances? ......... ............................... 12. If so, have plans been submitted to such authorities? -1 13. Has preliminary approval been granted by such authorities? `' Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. 18. If yes, name of water supply Distance to water supply 1 19. Is project site near a public sewage collection or disposal system ?..... A� 20. Name of sewage system Distance to sewage system /f 21. Date test holes observed: 22. Name / of Health Inspector: 23. Project design flow (gallons per day).......lJ p � .......................... 11/93 f 2. 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. `i 25. Has SPDES Application been submitted to local DEC Office? ............... d! rZ 26. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... Ale 27. Wetland ID Number ........................ ............................... 28. Is Wetland Permit required? ............. A/4' Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... AlG 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or Ale any other potential known source of contamination? ..............YES or NO DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal -areas in excess of 15% slope? ......................... 35. Tax Map ID Number .... N:.. 4.' .......... ............................... 36. Approved Plans are to be returned to: ................ Applicant Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I.hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of t_he Pena 7 law- SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: PUrNAM CXWY DEPARTMENT OF HEALTH DIVISION OF •' •' ' M V• L HEALTH SERVIJ __._.._ .. DESIGN DATA. SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE�.NO. j Owner �. ,� � _iCy3 Address 'Zwe fly /7c., rl &-j %�''CW�5l"er Located at ( Street) y G� , `�� Sec. 3_ Block �_ Lot 7 (indicate nearest cross street) Municipality E-1 A Ca Watershed Date of Pre- Soaking f ®7- - Vy Date of Percolation Test 8 HOLE NUMBER R CIS TIME PE RCO=ON 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 Inches Inches Inches 1/ a 14, 4 / J• ®� l Za 3 � _3 5 5 1 F 3 4 5 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 fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. / d� �z�r` ag v °/ 1 9 V1 014 2' 3' 4' 5' 6' 7' 8' 9' 10' ill 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: ,� �/7°vy/ 7'S� DATE: 1 9 Y DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Providedd O No. of Bedrooms ? Septic Tank Capacity / P o �� gals. Type Absorption Area Provided By Z L.F. x 24" width trench Other Name �i 1/� d2 Signature pF NEW Y Address �i�/� Z �'Fi��'!�jr�i`; j%v . SEAL / q a� _" pill; THIS SPACE FOR USE BY HEALTH DEPARTMENT OKY: Soil Rate Approved sq. ft /gala Checked by �` Date " L 5 t r I� a .t '3 � �4.h'F � { y � {F°i $�+i -Y� � ��JI�Id S3 �.LL � � A -Y,E +�' �i �.q G' 1. _ # V.. }�..{�'1 �. S � { � &Ar', "e�� F.s 'YM"�.4+�+x�' a..� I.�S�. ��:��7W.;. 'd:- '�...fi o wt+.��'yiY_�'�'-�``:i.,�^�`n. z ��, � ��'_�S.+of�.�a�r �'� r,�.. f a � +'�$'��