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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner Address eft oNX /Zo ,*D
Located at (Street) 91- i Tax Map 3 Block I Lot 6 6 2
(indicate nearest cross street)
Municipality 7,0 2,- � sd> a Watershed —,f r -Ftz .4,VGy
SOIL PERCOLATION TEST DATA
'Date of Pre - soaking ^7 Z2 OtO Date of Percolation Test 7 /13 f o c�
i
1
1-0%07-/0',37
3 O
4 ��-
2
'4"-3'7 /
4
.r
7. 5
2
3
liil6 -
J �4('
4
5
1
2
3
4
5
)TES: 1. Tests to be repeated at same depth until approximately equal
3
ZJ4
�f O
3 �7
rates are obtained at
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to N
submitted for review.
2. Depth measurements to be made from top of hole.
A-
Form DD -97
DEPTH
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
3.0'
3.5'
4:0'
4.5'
5.0'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
9.5'
10.0'
TEST PIT. DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. HOLE NO. Z HOLE NO.
r �pr "n". v. 6�:A D,,L)f -S 1 ,1V1
Indicate level at which groundwater is encountered &a �
Indicate level at which mottling is observed ,�
Indicate level to which water level rises after being encountered --
Deep hole observations made by: h, 77,5 , tom. b, H , Date 3 ov
,Design Professional Name:
Address:
Signature:
Design Professional's Seal
2
06/15/2000 09:31 8553772
BRUCE R. FOLEY
Public Health Otrector
ZARECKI
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster,' New York 10509
PAGE 02
LORE7TA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
REQUEST FOR FIE. L/D G.
TESIIN
/
ATTENTION: a ADAM STIEBELING GENE RE, ED
All information below most be fuJU completed prior to ally scheduling. DAT& —(oLlske)
ENGINEER OR FIRM: ZAM00 PRONE #: "5-377
REASON:
DEEPS. !C PERCS: it PUMP TEST: o
ROADISTREET: 91 IIARMON Y RoAD
TOWN: TAS'MA
SUBDIVISION: __ IvA
OWNER: kA9JAJ FALWCKZ
/o'>- on
n 10 a R Ali o►l ► ► t t `� ►
YES al( Nq
E3 Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs.
o S/ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
o q/ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
Proposed SSTS design flaw greater than 1000 gallons /day or SPDES Permit required.
Proposed SSTS for a Commerical Project.
,p.
It is the responsibility of the design professional to provide the above information prior to soil testing.
This Department wilt determine the NYCDEP project status (Joint or Delegated) based on the
response. It you answered j&f to any of the questions, NYCDEP must witness the soil testing. This
Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design
Professional and NYCDEP.
If a project has been determined 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 to schedule re- witnessing of the soil testing with NYCDEP.
I.-Olt CUUin y UsL• 6rmy Acre i pcEd, g
RATE: Z9 1.2, Q 3 TIME: �3 40- i O p
cowL;�n:
OTCLDTENT)
/e.F (-
06/15/2000 09:31
ZARECKI
Assoc' UTEs, L.L.C.
Consult ng Engineers
Land Surveyors
Land Planners
Joseph Zarecki, PI
Jeffrey Hecker, t5
Curt Johnson, MP
8553772
ZARECKI PAGE 01
FAX C�V ,ER SHEET
Mr, 7
Date: 6 WJ/ 100
.loti No..g060-QL0 Z.
11 West main sr.
phppg;�rf�_
No. of pages:_
Vawfing. W 12564
(914) 855 -3771
(914) 8553772 Fax
Fox: � /8 �^' X72
From: VA IMI MUC
email: zareck377I Oool.com
31 8oiley Ave -
Ridgefield, CT 06877 .
(203) 438.7094
(2031436-7157 Fox
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GROUND ELEVATION �AP�
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