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HomeMy WebLinkAbout2151DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 30. -2 -44.2 BOX 19 02151 ' b . a� a, W Y� WLLL UVrlrLLil.Vty Azrur" DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only i'° U � WELL LOCATION STREET ADDRESS: wNlvtl / 1 Y TAX GRIO NUMBER: I /'0C/z),) / / "j&— - WELL OWNER NAME: �° 9 i» : ADDRESS: /'J F/�)1A -1 G'5T z,4 Lac ti TE 0 PUBLIC USE OF'WELL 1 - primary 2 - secondary JZRESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND.IHEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _ _ gpm. /NO. PEOPLE SERVED _I- / EST. OF DAILY USAGE_ - O gal. REASON FOR DRILLING N(NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ,305 ft. STATIC WATER LEVEL 3 0 ft. DATE MEASURED 47136-20 DRILLING EQUIPMENT 0 ROTARY WCOMPRESSED AIR PERCUSSION • ❑ DUG ❑ WELL 501NT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING. ❑ OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH tL MATERIALS: '9STEEL O PLASTIC O OTHER LENGTH .BELOW GRADE ft.' JOINTS: O WELDED THREADED O OTHER DIAMETER _--(2— in. SEAL: RCEMENT'GROUT O BENTONITE OOTHER WEIGHT PER FOOT lb./ft. DRIVE SHOE:EYES ONO LINER: ❑ YES WNO DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? .SCREEN DETAILS FIRST 0 YES. ONO HOURS SECOND GRAVEL PACK O YES ❑ NO GRAVEL SIZE. DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED 11 tests were done is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER O YES NO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach.- DEPT FROM SURFACE water Bear- ing welt Dia- In FORldATTON DESCRIPTION � � ; CODE, ft tl WELL DEPTH It. DURATION hr. min. ORAWOOWN ft. YIELD gFm. Surface 00 EA-1 /ho /qs Fib i4c7vR4 /l's Cr2.AA/ /;E �90 a f=rz/� cTV�E WATER ❑ CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? OYES ONO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME DAff ADDRESS P--b-j5— ICd 11 .�2 SIGRATURE C.4P— y1EL) k) 'Oro, 7V Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y.. 10598 (914) 245 -2800 Director: Albert H. Padovani M.. T. (ASCP) T_ � CY LAB # 32-007945 Date Taken /i .�Ll- lG} Time: Date Rc'd: i/- 3a -9d Time: Date Reported: DEC. 0 3 9990 Collected By: PO /Client # Referred By: Sampling Site:. if Phone REPORT ON THE QUALITY OF WATER INORGANICS (mg /L) MICROBIO GICAL 100 ® Alkalinity _ Chloride _ Copper — Detergents, MBAS _ Hardness, Calcium _ Hardness, Total Iron _ Lead _ Manganese _ Mercury. _ Nitrogen, Ammonia _ Nitrogen, Nitrate _ Nitrogen, Nitrite _ Phosphate, Total _ Silver Sodium _ Sulfate _ Sulfide _ Sulfite Zinc PHYSICAL/MISCELLANEOUS _ pH (S.0 ®) _ Color (Units) Conductance (uhms /c) Odor (TON) ® Turbidity (NTU) Standard Plate Count ® (CFU /1 mL) Membrane Filtration Method j Total Coliform 4 t Fecal Coliform _ Fecal Streptococcus Most Probable Number Method Total Coliform Fecal Coliform Fecal Streptococcus - Presence /Absense (PA) Total Coliform P A KEY FOR TERMINOLOGY CFU = Colony Forming Units IT = < = Less Than GT = > = Greater Than NA = Not Applicable SA .= See Attached TNTC = Too Numerous To Count REKARKS OMMEN For ab se (For Lab Use) SAMPLE TYPE: (Check One) Potable ._ Non- potable OUTGOING: (Check Each) HNO HC13 — H2SO4 NaOH ZnOAc _ Na2S203 Other: INCOMING: (Check Each) v"LE 40C GT 4 /LE 200C _ GT 200C _pHLE2 .pH GE 12 Other: NYS ELAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE IME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) (NA)� MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE L DRINK* ING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF S COLLECTION. x L L 7 /87(Rvsd1 /90)RWE o Padovani, MoT. (A , Director Cate FINAL S�� wit z CF, Su =Dri:sir L:.T nRE- �_ SS z =.= lcr�- as F=-' �ro�E✓ cl�n� b_ Fri I . - D� c= L�sa�.?.c 2:1 c i Gy LL; _ tiV �Ti= fit_ SIC _ DP C. SCj rCL E`:1 15 f =a-, cDs E_ ACC CCL= _i�vc =a_ cs-- C. cc soa L_r�c� C_ =�C' W_ =2n lC L= c- - f=cr I1,4 L I32 m/:--c L. C I Q i �- _ -_ C�� __'c -- �- 1 - 20 E. Rcc:z a cwaE fcr E_:-.- =_cm, Su In tz. Enc 1 L" P, E:1=1 e= I h. . L'tD ca LCS= c_c- -`..SC 2. Cti er-F-I c- tank I 6. cvcl e w ==_s be E. E=us= lc=- r- cCCrC�`' pl�ls c- C_: C- 4 _ c= 7-E-2 c- :.tic^ Di�nc C � _ -IT: _5 rec C. c_ �YcS T.rCC_ ': C_": L• ma=r' _ C. ]: �,i Lac f" i•c:i W- th 1n5_C` cf Ecx IC. _ =_cl CCl:-.= T_nc 5 - ^.nEc I - _ -- ---- - - - -- - -- _ 1 1 C_„t_r - c?+' _ °'- -r-= - -,Z r•' c' _ , -- F. ?��-V f --=,t 52S a'_"— -- _- o, f ' (►itt!�Y vLi a -r?! h F f?I IA i3'+7 fYir R W71 A 'f �ieriiY, lnslee "+saw 'wb.� I e� I :e V . 0/88 °;.qir,� +T qi y I:Uf• AI Iii a rirar. l�avltia.i "! i l a{ 1 ,' I:�xy�,b�+ >n P sr• °,.�:.n f *ek -� f f .rmir I � 1 kr.mc <�J ■ [.tdmn ■ �N 1 n5.71 ms gyp v`cL ll�¢ Atva l� m S329M Sydem b e2 .,� ILL Ylo Lo lxr- U9iRiW p Wiz / P6� ' p psi R s/E " 1 en mavob zt� Dead 6F �'1C. • ems, 0 rewasont that 1 Orn wholly and tornplotoly roayansiblo for tho dotion and locution of .the propoeOd systorrm(e) 1) that the m arato sears © dia owl'systom Obotte extribod.tvill be constructed as ahmon on the appro"d arnandment there to and in Octordanco with the r a r �a `ons O Inc. u na County Dowtrrtent .09 "W62h, ang that on comwou" th.Oroof a "Certificate of Construction oOmOliance ,t • pV of ft4slthtvill DO MOMPted t® 240 Depaftn=t, ana o written wrantoo. will bo ;furn h)s QUccomwe. hors. a Q>4itAa ®u r thtattek9 buimor wlll Obco Iii pose) 69pasat� co"Ition any Dart of MIS C9wOgo 'disi4mi. owr durkq; tot parr 04 two 8) TJCafsion '` latelly lol _tO4ttQ+ito 00 the Is�+t- am 09 tWa OXFOtral ®f tha ccniviamo of Con4ruction :Colnpeianca; the or. Inal sy . ea a r thcro80. a) that the drilled x 611 dosw� coovo tim Do Oncated Go s on Um aMoavco Ma on(O that Mid XII will ®o in n � `ey c>. soms. rubs and rqu ns Af thQ 'putRarw Cato A Q.Ottrttfl ®- e� ,00 t1iL3OtW. .// 14W. VJ7X APPROVED ROOD COMTRUCTIONt This approval expires two years from the dote Issued unhass construction of the building hoe boon undortataon and is re"Wato for comet or My bo agamucs or rvld190Cd whton considered nocomry by the COntmissionor Of "1m1eh. Any thanpo or Oltwation of construction =Utroa qwq Ownlit.. Avoovq fir t71CS�o0o1 Of domostit WRItary- /m and/ o @S or cu"IV only. Or I Y./Nu,. A-5drese a 1 - 1 — V Fee En6loseo.a Amount too — Separate Sewerage System'bdllt by �zSo: Coaefsft of - Gallon Septic Tank and. P+U� y� . Town or ViHfp Tax Map BlockI_Lot �- Sabdfvlalo. Name •• Subdv. Ltit Date Permit Issued T KY Water Supply: Bc Supply From pp+� Address on Private Supply Ddged by wJCN - VALK Aim L Type i Lot Size Has 1 Erosion Cnntrnl RPPT Cram= 1 Pt- Pfl% Nundw of Bedrooms 4 Ha. Garbage'Gdnilee Bee. I.staped? 0,0 Otber xegaleemeets I certify that the systems) as listed serving the above premises ver'' constructed seentially as elbow. on the plans of the,corpleted work ( copies of which are attached),.and in accordance with the standards, rules. regulatio i accordan w the filed plan, and the permit issued by the Putnam County rtment Of Health. oats ��' !41 1 Cartifled ey. P.E. R.A. 7 ��c 'I > L,i 'Address zip. - 7unVi'K �! %FJ 1Cj Liana No. RU . Any person occupying 'promises saved by. the above system(:) shall promptly. take such action'as may be necessary to Imes the correction of any, unsanitary conditions resulting from such usage. Approval of the separate uwaayl= systern shak,become null and void as soon as a putt% unitary -wef becomes available and the approval of the private water supply :lisle become nult and ?void when a public water supply becomes available. Such, approvals are subject to modification o change when, in the judgment of the'timmluloga of Health, sues revocation, modification o► change Is necessary. oa - t - Title 3/59 PUTNAM COUNTY DEPARTMENT OF HEALTH F Dlvlaloo of Znvboonmtal Heeftb SwAvea, Caeoief, N Y.10512 Engbaeer Mart I? &A& �l/ V `b lA P.0 H D. Peeenft N 30 , -r D, - q , Z Or I Y./Nu,. A-5drese a 1 - 1 — V Fee En6loseo.a Amount too — Separate Sewerage System'bdllt by �zSo: Coaefsft of - Gallon Septic Tank and. P+U� y� . Town or ViHfp Tax Map BlockI_Lot �- Sabdfvlalo. Name •• Subdv. Ltit Date Permit Issued T KY Water Supply: Bc Supply From pp+� Address on Private Supply Ddged by wJCN - VALK Aim L Type i Lot Size Has 1 Erosion Cnntrnl RPPT Cram= 1 Pt- Pfl% Nundw of Bedrooms 4 Ha. Garbage'Gdnilee Bee. I.staped? 0,0 Otber xegaleemeets I certify that the systems) as listed serving the above premises ver'' constructed seentially as elbow. on the plans of the,corpleted work ( copies of which are attached),.and in accordance with the standards, rules. regulatio i accordan w the filed plan, and the permit issued by the Putnam County rtment Of Health. oats ��' !41 1 Cartifled ey. P.E. R.A. 7 ��c 'I > L,i 'Address zip. - 7unVi'K �! %FJ 1Cj Liana No. RU . Any person occupying 'promises saved by. the above system(:) shall promptly. take such action'as may be necessary to Imes the correction of any, unsanitary conditions resulting from such usage. Approval of the separate uwaayl= systern shak,become null and void as soon as a putt% unitary -wef becomes available and the approval of the private water supply :lisle become nult and ?void when a public water supply becomes available. Such, approvals are subject to modification o change when, in the judgment of the'timmluloga of Health, sues revocation, modification o► change Is necessary. oa - t - Title 3/59 PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Duildi g to ee e t Building Constructed by Pk 9k-- Location - S eet � jf, -- Municipality Building Type 5-1 1 I (L Section B.l.oc:k Lot /off ,-2 3" q1-P / JA Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, 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 immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by we 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 Director of.the Division of Environmental 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. Dated this day of ��- 19, Signatur e Title (Owner ) Siguhture Corpor/a/tionn Name (if CCo.3:po () ,. Address , rev. 9/85 mk rporation Name (if Corp.) ess J S 1, el.;4 0% e PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Duildi g to ee e t Building Constructed by Pk 9k-- Location - S eet � jf, -- Municipality Building Type 5-1 1 I (L Section B.l.oc:k Lot /off ,-2 3" q1-P / JA Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, 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 immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by we 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 Director of.the Division of Environmental 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. Dated this day of ��- 19, Signatur e Title (Owner ) Siguhture Corpor/a/tionn Name (if CCo.3:po () ,. Address , rev. 9/85 mk rporation Name (if Corp.) ess J S 1, el.;4 0% Corpor/a/tionn Name (if CCo.3:po () ,. Address , rev. 9/85 mk rporation Name (if Corp.) ess J S 1, el.;4 0% DEPARTMENT OF HEALTH Division of Environmental Health Services 110-OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL AA� (j� PCHD PERMIT � d�� ' WELL LOCATION f eet, Ad ress Town/Village/City i %- U- Tax Grid Number ._ Z WELL OWNER Name 5_ it2 ► c Mai Address riva te O Public USE OF WELL 1 - primary 2- secondary RESIDENT L 0 BUSINESS 0 INDUSTRIAL C PUBLIC SUPPLY O FARM U INSTITUTIONAL ❑AIR /COND /HEAT PUMP OABANDONED O TEST /OBSERVATION 0 OTHER (specify O STAND -BY p AMOUNT OF USE YIELD SOUGHT __2 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE _4 gal E3UPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION. CI ADDITIONAL SUPPLY WNEW SUPPLY NEW DWELLING 17 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DDUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name fat G "MCUrS,,�A Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: TOWN /VIL /CITY LOCATION SKETCH .& OURCES OF CONTAMINATION PROVIDED N SEPARATE SHEET (date) I (signature) PERMIT TO CONSTRUCT A WATER WELL rr�� "1�11369 This permit to construct one water well as set forth above`�s 1.l granted un,_der the provisions of Subpart 5 -2 of Part 5 of the New York State CoMle i ll provided that within thirty (30) days of the completion of.,�� ter °,well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. --- Date of Issue: : fc, y 19 � Date of Expiration: 19 wit Issuing a Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Rev: 10/88 Pink Copy: Gamer Orange copy: Well Driller t� I i c �I1 '1 i_1 •c ' V1 r V U (�1 O m "1+x;1 I•a U) r=; Q r+ ty [)1 O tl) U) .t' U, U v) ll� r -1 I 1 =• L� W S �1 L �y ul U 1 ti l_! j t Ur. t '1 to Ul I 1> tll I -r I , I ci i [._I u Ivt 1 • • I A ' S. I — Irl w � 't r — ,- — — r -I 111 f:l I.• U — — +) tr) Ii, UJ — — — — of U i�i — — — — — -� — — O1 00) 01 — — v1 r) IJ .1.) Qi�L — — t)I r; 1- C1 • -t it ,-r IfJ tr� ltl 1C1 7-, _ lr�) F 4 ' �I •v� ••i •IJ of U 1.1 U) Itl 1: U, •, r)1 � (I) -I r_) r_� ttl ,_ UI C?t (r) \ . -I I- I ( •ly ra. 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I q CI ry ), H ..- O 1 r tiii '3 ()' -) lu u) ti {Vi V N Q L14 �4 l� 1 W w W tit U I tl1 I U I J vt 1,, •) n.1 i)J i U IrI L1 OI •' I U tP tIJ Ft l c" 13 t t r[ 1 Cwt l ) 1 , ttj N r, t- L i 4{ r rVl Q l) ,tj 4t1 ..-r ill • r I ., J 11 i N lr) U l [.1 -U I 1'1 ftl nl U) .LJ ' c r- 11 • -f .r IJ U) u .N u rj a� c •rl1 r-(N r-I r, r f r (l t I 1'1 1:1 1 1 -I ill Ill I1 L, I�rt rl l .a it nt •.1 11, rl r� r1 v 1 MIII •I r, uI .. 1 •tl r �•, 14 t'I ftr -ct fi 1 I . 'IJ U) — — — — — — — — — — — — A — — — — — — — — — — — -� — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — In Q S • fl i. I (11 ((r U I tl1 U I J tU rl l tJ I r1 '1 i 11 S.f u 11 V-i w ►� nl , -1 'r 1. > to u-1 \I DIVISION OF ENVIRONMINIAL HEALTH SERVICES DESIGN DATA S1=rSUBSUEACE SEWAGE DISPOSAL SYSTIM pp FILE NJ: Address a c ` -A J Located at (Street) �> c6 :z Sec: Block i -Lot h r (indicate nearest cross street) •. Municipality. Watershed k-�&ks a. SOIL PERCOLATION DATA RBQMM TO BE SUBMITTID WISH APPLICATIONS (TEST Date of Pre - Soaking. Ic 4.j Date of Percolation Test 1k' bi HOLE l 2i . NUIMER C= TIME PERCOLATION S PERCOLATION Run. Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Mina Start Stop Drop In Min /In Drop .� . g..7 Inches Inches Inches 1 Z, y i 2 25- 2� 3 _._.. ► q.. P, •. 2. 3 DEC t . PUTNAM COUrN? . 5 NOTES: 1. Tests to.be repeated at same depth.. iintil'approximately 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. rev. 9/85 l 2i . Z 2 S D •. o - 2 4 ?G 2.� 2.� .� . g..7 •. 2. 3 DEC t . PUTNAM COUrN? . 5 NOTES: 1. Tests to.be repeated at same depth.. iintil'approximately 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. rev. 9/85 ..d DEPTH G >L. 1° 2° �4mlc PAS 4° s. 5° 6° 78 TEST PIT DATA RDQUIRED 70 BE SUBMITTED wiTH APPLICATION DESCRIPTION OF SOILS ENOOUN MED.IN TEST•HOLES HOLE__ NOe i 14° ' INDICATE i.EVEL'AT WHICH GROUNDE=R IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP BOLE OBSERVATIONS MADE BY :. DATE: DESIGN 2 Soil Mate Used Min/1" Drop: S.D. Usable Area Provided Noe of Bedrooms Septic Tank Capacity tz.sJ gals. Type Absorption Area Provided By _ .L.F. x 24" width trench i'3EVY y Other Name e,:= Signature`ry`?� G .� Addy • eS s 'L I2 tA SEAL bi p No• 431 x' �.° w NROFESSiU�`f�. THIS SPACE FOR USE BY HEALTH DEPARDMNr ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PUIVM COUWY DEPARi 191 OF HEALTH DIVISION OF 1'.• 191 Y• HEALTH SERVICES IINDIVIDLIAL vaTER 5UPPLY/SUBSURFACE SEWAGE DISPOSAL YD FIELD INSPECTION REPCORT (Wire of er) �� �eet Roca io INITIAL SITE INSPECTION --ova -q) Wetlands on/or proximate to property...... ..... Property lines or corners .found................... Can estimate house location ........................ Willdriveway need cut .............................. AD 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 ............................ Access to nr000sed well location for drilling..... D.H. 1 Lot P Depth to G.W. Depth to rock D.H. - Deep Hol G.W.- Groundwate D.H. 2 Lot D.H. 3 Lot Depth to G.W. E° Depth to G.W., Depth to rock (�' Depth - ock Soil Description %• A/Viezcri; ti c 0 ft. 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. • ft 12 ft. DA'L'E: Soil.Descri tion 0 ft. 3 ft. NO COMMERrS 9 ft. 12 ft. F D.H. - Deep Hol G.W.- Groundwate D.H. 2 Lot D.H. 3 Lot Depth to G.W. E° Depth to G.W., Depth to rock (�' Depth - ock Soil Description %• A/Viezcri; ti c 0 ft. 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. • ft 12 ft. DA'L'E: FINAL SITE INSPECTION. INSP.BY: NO COMMERrS House SSDS located per approved plan ............. F Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Roan 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 beriroans checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench.. ............ 15 ft. of- peripheral soil horizontally fran trench ..... ............................... Boxes properly set ............................... Cculd surface runoff from driveway, roads, . ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRAD% OF SITE ACC =A=. S G \ Q V' U j ck: U � �j Q O � � O 0 ly � to y S c ,Q O V 0 r• ti OM AREA: 18.358 ACRES a UL13tiN uomiry L61`.;11 T:C1•_L!L ut uksa1Li, leis on of Envir nmental Health Serviost_ .eproved as noted for conformance with .pplicablo Rules and Regulatlom of the 'utnam County Health Department, ;ian� �, Tit -l.a at 9 SEPARATION DISTANCES IN FEET 14 151fi 17 18 / 19 A-, / 1 Fr Dre//ih)' / l i ib Pc/e r v" n i ` =Z ! t J 1 J 6 7 6, D !O It /Z p 14 13 16 17 Is 19 2-9 7s- 71 93 88 9t 77 SL s$ 6Y G9 79- IJl 108 11Z- i/J 117 JW IzS 0 5$ Nl 13 i/6 no 1L3 ju 71 83 87 YZ 97 ion /9S yF 13-0 /Q /S 4o C 14 151fi 17 18 / 19 A-, / 1 Fr Dre//ih)' / l i ib Pc/e r v" n i ` =Z