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PUTNAM COUNTY DEPARTMENT OF HEALTH
rt
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Za 1
Re: Property of
Located at�
(T) "_�_N�E,.�klSection Block Lot
Subdivision of dL- \116-1 i-L-
Subdv. Lot # / Filed Map # Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer or registered architect
(Indica e
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 supervise the construction of said
system. -.or,. yst.ems__in. confjo,rmity. with the provisions -:of- Article ,1..5 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned
.E. R.A. ,}
Address
Telephone
Very truly yoArs,
Signed 11111,60101e, 11AWAA
wrier of perty
Address
Town
Telephone
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION.OF-.ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N.- Y.r 10512 -
DESIGN TA SHEET - SEPARATE SEWAGE - DISPOSAL SYSTEM FILE'. NO
Owner, Address.
Located at (Street _.-Sec., Block . -Lot
�Indica e nearest cross street)
Muni ci pal ity:]��� Watershed AvV-:f--
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME .
PERCOLATION
PERCOLATION..
Run apse
No. Time
Start -Stop Min.
Depth to Water
From Ground
Start
Inches
Surface
Stop
Inches
Water Level
in Inches Soil Rate. -..
Drop in. Min. /in drop'
Inches
2j
71
_
3q'd( -9LZZ
r
4 q:2-15 -' °4q a1
3 2A
5
1
3
4
5
Notes: 1) T&'ts to be repeated at same depth until approximatelyy 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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION'OF SOILS ENCOUNTERED IN TEST HOLES
D8PTH:. ..:HOLE,.:. N0.._., l HOLE NO _ .. HOLE NO.._. .
G.L.:
6
12"
18"
2�+"
30„
42"
.4811
54"
60"
66"-
72"
L-
7811
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED "
INDICATE •-IZVEE• TO WHI• - H- .WATER - LEVEL RISES K-FT -ER- BEING - ENCOUNTERED
TESTS MADE BY- Date
DESIGN
Soil Rate Used f Min/1 "Drop: S.D. isle ed .���
o
No. of Bedrooms Sept'c Tank Capacity giCHA
Absorption Area Provided By_ 5,.F.x24" �P w�i enc
a.
Address
THIS SPACE FOR USE BY HEALTH DEPAMEM ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by
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