Loading...
HomeMy WebLinkAbout2286DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.09 -1 -3 BOX 20 .? IN Ir MANI ., aNg 16 .` 10.1y IN i Rev.4 3186 WN Located at Owner /applicant Melling Address PUTNAM COUNTY DEPARTMENT OF HEALTH nn of Environmental Health Services, Carmel, N.Y. 10512 Engineer Mast Provide PV — 1,1 P.0 -u_n_ n.,rm!t u— 3 FIANCE FOR SEWAGE DISPOSAL SYSTEM Separate Sewerage System built by r Consisting of Gallon Septic Tank and Ell_4AM VA lle, Town or VMMe TaxMap Block Lot ,Q 0 qd Subica slon Nallhe 17J _Subdv. Lot # Date Permit Issued ��� Pr Water Supply: Public Supply From Address or., Private Supply, Drilled by r Address ZWA ! _,_ ki a � Butldfng.Type f SE.O AAACI I Has Erosion Control Been Completed? / Number of Bedrooms Has Garbage Grinder Been Installed? Other Requirements I certify that the system(s) as listed serving the above premises were constru ease tie s shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and req ti a, n ac rd' ce with the filed plan, and the permit issued by the Putnam Count De rtment Of Health. Date Ce►tif d by P.E. R.A�.- Address License No.�lo� Any person occupying premises served by the above systems) shall conditions resulting from such usage. Approval of the separate available and the approval of the private water supply shall become subject to mopificqion or change when, in the judgment of the Date J By pr ptltaka such acttofi as may be neuaasry to soeure the correction of any "unsanitary is rage system shall be a null and voitl as soon as a pubt ?z sanitary sewer becomes n 1 nd v wh a p bite water supply becomes available. Such approvals are C issio r o4 1 , h r ocatibnL m"fleation or change Is Title PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER TO PROVIDE PERMI # ON CERTLFICA MP NCE. 3� Division of Environmental Health Services, Carmel, N. Y. 10512 PERMIT # CONSTRU TION PERMIT FOR SEWAGE DISPOSAL SYSTEM / oWM, 01 ��1'j�401 IU4V / / /r/�, I Town illage Located at a-SAkE -C 904r> Tax Map / sock tot Subdivision /° i5gcw- owner/Address STA �°�./ � l � -^e4}IG�W� Building Type ® ' Lot Area Number of Bedrooms 2— Design Flow G /P /D e Separate Sewerage System o consist of 100, To be constructed by Cam. Water Supply: Public Si Private S Address Other Requirements Renewal _0 Revision _ Date Of Previous Approval Fill Section Only ❑- P.C. H. D. Notification u:. I Caul. Septic Tank and ZS2 f77 ` wibre° rfi°'4 Address S 1. 1 represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulations o e u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately following the date of the issu- ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be install in act an ith the andards, rules and regu aTf o s of the Putnam County Dgpartfnent of Health. Date r Address L­1 'w— W APPROVED FOR CONSTRUCTION: This app oval expires revocable for cause or may be amended or modified when cc requires a new pormit. I Approved for disposal of do es Signed P.E. `Z R.A. icense No. 06V n r from. h date issue nless c struetion of the building has been undertaken and is a nece ry by missioner Of Healt Any change or of construction wry s ge, an to wat r supply nly. Z. �J�JA Titles WELL LOCATION WELL OWNER USE OFVELL 1 - primary 2 - secondary AMOUNT OF USE REASON FOR DRILLING DEPTH DATA DRILLING EQUIPMENT WELL TYPE CASING DETAILS SCREEN _:;:;- DETAILS _. ­ , U. WELL COMPLETION REPORT Office Use Only. DEPARTMENT OF HEALTH� siop_ pf.,,Envirormental Health_ Services UTNAM COUNTY DEPARTMENT Ot.HEALTH TAX'GRIO NUMSER:,- IVATE ESIOWAL 0 PUBLIC SUPPLY 0 AIR/COND./HEAT PUMP L,/6' ABA hOONE'D 0 Ell' USI USINESS 0 FARM ❑ TEST /OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL 0 STAND-BY 0 YIELD SOUGHT gpm./NO. PEOPLE SERVED BEST. OF DAILY USAGE­ %NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION N 0 0 C EP LACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL WELL DEPTH ft. STATIC WATER LEVEL _�ZJDATE MEASURED 4AP2 �KROTARY 0 COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): P, • SCREENED O,OPEN END CASING. )RrOPEN HOLE IN BEDROCK 0 OTHER TOTAL'LENGTH DIAMETER WEIGHT PER FOOT DIAMETER (in) FIRST GRAVEL PACK 1 0 YES ❑ NO I GRAVEL SIZE. WELL YIELD TEST If detailed pumping MffHOO: 0 PUMPED t tests were done is in-, )I�COMPRESSED AIR formation attached? 0 BAILED ❑ OTHER ❑ YES 0 NO WELL DEPTH DURATION I DRAWDOWN YIELD It. hr. min. It. gpm. WATER . CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES 0 NO PUMP i RMATJON TYPE CAPACITY MAKFR.09) Z!,�OEPTH MODEL _40LTAGE130/tv 2-1 4— ft- MATERIALS: )EtSTEEL. 0 PLASTIC ❑ OTHER HER ft. JOINTS* 0 WELDED JZ H THREADED 0 OT ER in. SEAL: ❑ CEMENT GROUT 0 BENTONITE ETHER lb./ft- DRIVE SHOE� ES ONO LINER_ QYET,-QNO SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? D? ' OYES ra, U NO I DIAMETER Imp m OF PACK DEPTH BoTra OEM It. WELL LOG WALL more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM 'W,t,, Welt SURFACE Pear- Dia- FORMATION DESCRIPTION CODE ing meter land Surface -4 STORAGE TANK: TYPE _4�,�-,Y-,;��--W-#- CAPACITY r PAL. WELL DRILLER NA941 DATE ADORES Sl GFIMRE L/ THESE RESULTS INDICATE THAT.THE.WATER SAMPLE.L('WAS ) (WAS NOT) (NOT APPLICABLE) OF .A SATISFACTORY�SANITARY QUALITY - ACCORDING. THE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, A TIME OF COLLECTION. Albert H. Padovani; M.T. (ASCP), Director LEGEND 'RDS = Recommend Disinfect - ing Water Source < = less than TNTC = Too Numerous Too Count _ Yorktown Medical Laboratory, Inc. LAB IY -- 321 Kear Street „ Collec.tion.Station Used: _ Heis! N Y 1Q598 Yorktown ght Carmel Peek Peekskill — — (914) 245 - 3203. Director: Albert H. Padovani M. T. (ASCP) Date! Taken:,' Date. Received c _2s d / /u Date Reported- 3 -�22_� a Collected .B 3 (�/j2%r'�L L cS' Referred By �%p AIJ�C%YL j / v �/ .J Sample . Source: GU ,. L LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF :WATER GENERAL BACTERIA. Standard _ Plate Count per 1.0 ml. 6.(� (Agar plate @ 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT) V Total C.oliform ml rer, 100 THESE RESULTS INDICATE THAT.THE.WATER SAMPLE.L('WAS ) (WAS NOT) (NOT APPLICABLE) OF .A SATISFACTORY�SANITARY QUALITY - ACCORDING. THE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, A TIME OF COLLECTION. Albert H. Padovani; M.T. (ASCP), Director LEGEND 'RDS = Recommend Disinfect - ing Water Source < = less than TNTC = Too Numerous Too Count .. Owner or Purchaser o Building— Muni ipality Bu ilding Constructed Sir Section ,44jei SW4P- !mil l� : (.V�ilT �G��/�irlc3 6941 k- 1'4fie�6 Location - Street Block Building Type rot GUARANTY OF SEPARATE SEWAGE 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 guaranty to the owner, his succes- sors, 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 initial use.of'the sewage disposal system, or any* repairs :Wade by me to such system, except where the failure to operate properly is caused by the willful or negligent. act of the occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the de- termination of the.Director of the Division of Environmental Health 5er vicas of the Putnam County�_De artment- of Health as t,o; whether_ or _notw,w Pa Zure of the system towoperate was caused+ by the wil fu i egligent } act of the occupant of the building utilizing the sys emm � Dated this day of 19 Signature Title /JJ1 L-d I (If c rporat on,— give name and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmen Mahc , N4 Department. of Health A.CIONSTRUCTi ®N 6NC. �� tion ®Trucking o:Equipment Hauling •jSepUc�Systems- Specialist �p,Soil o Fill'a Gravel ®Black�Top ; shollow�Ri9r��- RFD�9�$�Boxx4,7�4 �; „, �� �� ac`New York 10541 x(914) 62135738 1 ------------- APPENDIX C o -.7 a FINAL., SITE INSPECTION ION ER f_ r MIT TM #^ OR SUBDIVISION LOT # IV. V. Vi. Y E-c: 14 C CONIS .SEWAGE DISPOSAL AREA a. SDS area located as per approved plans . Fill section - Date of placement 2:1 barrier. LGTH WDM AVG.DPTH c. Natural soil not stripped.. d. Stone, brush, etc., greater than 15' fran SDS, area. e. 100 ft. fran water course/wetlands. SEWAGE DISPOSAL SYSTEM ....... a. Septic tank size,,--'1,000 1,250 b. Septic tank ins eve1 c. 10' minimum fran foundation d. No 900 bends, cleanout within 10 ft. of 45.0 bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX properly set g. TRENCHES ,1.,Length requi Length installed—) 2. Distance to watercourse measured: ft. 3. Installed according to plan ,4.' Distance.center to center 6 .�5. Slope of trench acceptable 1/16 1/32 6. 10 feet from property line - 20 feet - foundations .7. Depth of trench < 30 inches from surface 8. Room allowed for expansion, 50% 9. Size of igravel 3/4 - 11" diameter 10.-De th of qravel in trench 12 minimum `11. Pipe--ends' -tapped= ------- ---------- h. PUMP OR DOSE SYSTEMS 1. Size of pump chamber- 2. Overflow tank 3. Alarm, visual audio 4. Pump easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed by Health Department estimated flow per cycle HOUSE a. House located per approved plans. b. Number of bedrooms WELL a. Well located as per-approved plans AAJ J k, b. Distance from SDS area measured J ft. C sin �g 18" above grade. � d. Surface drainage around well acceptable. C -e- .OVERALL WORKMASHIP a. Boxes properly grouted c- cc -p-,1 C-6 1 e b.- All pipes partially backfilled C. All pipes flush with inside of box d. Backfill material contains stones < 4" in diameter e:. Curtain drain installed according to plan 1 -CA e 8 f. Curtain drain tected & dir.to outfall pro exist.watercourse 9. Tcot'inq drains discharge away from SDS area h. Surface water protection adequate io RFrosion controi provided on slopes greater e, ' PUTNAM COUNTY DEPARTMENT.OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re.: Property of Located at Date g-- S/46 tZE - )e4lz' (T) Section / Block 19 Lot Subdivision of ic�04?-4XI4 8zoo< . Subdv. Lot # 42dj Filed Map #Q.� Date 2 Gentlemen: This letter is to authorize a duly licensed professional engineer 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 supervise the construction of said systerri _or;- systems' 'iii' conform�t it,!h..the provisions. ;o;f "Article_ 145_. 147, Education Law, t%' Health Law, and the Putnam County Sani- tary Code. Cokftl pOIIAP' � truly yours, s ®1. Signed Countersigned: r Owner of Prope ty �2�� P.E., R.A., # Address Ci C g=LAi Ltd ei Ci JO /C /O U� Address Town OAtkr J Telephone J 43j Telephone 44'0" 14'5* 7 *4 I. 3.0� 17'3 10*6" 21 *0' 3$.0. C' PLUMB WALL ! BATH s + • '.'yr T". si . 11 e°b 0 O F -- l • Iy . il < �MN N • F- 3. 0 DROP �tILiN N 0 CCB_Al O D ❑p C ;, HALL �.. I 6.7a 5.0� BEDROOM t2 2.10 7.1 10.0" 2.0� ;•� KITCHEN / DINING BAT +1 • fff���111 O iX 01. CATBiDRAL CSILING i• r O I • 1 1 _ 73� 10,0 i. ShlOKB. DZTZC70Ti CATBYD2AL CRILING LIVJN.G ROOM F. f , i iO 11 loo FLOOR PLAN • b 'I a • �o b O n �wm i� Af dl s� u' a+ a1 r+ ri s s� �t is S: 4. Y� PUTNAM COUNTY DEPAR MENr OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEDGE DISPOSAL SYSTEMS (Name of Owner) REVIEW SHEET - CONSTRUCTION PERMIT DATE REVIEWED: 31 �D (SCP (Street Location) 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 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 /Glitter 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 = Nb: 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 "0; Type pipe No Bends; Max. Bends 450 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,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran 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 Ctrtt aztlet ln" above latecat b. DMIKO M B7k IET M 1. Inlet kr ext min. 2" aboie cutlet invest. 2. All valets at sane elo aticn. 3. Outlets 1" to 5" above tank bottan. 4. Minimum 12" bey irrg clean sand cr pea gel. 5. Inlet baffle. 6. Mmdm n 12" cover. 7. Fen able cover fcr as Mss. 8. Smisd pipe joints (as#a.lti.c cr equal) . 9. Mcpe attlets at 1/8 inv/ft. (1 %) . cutlEt. 3.. Iatemis fly with bottom. 4. TiGht joints pipes bat em bcxLs. 1. Slcpe 1/16 in. /ft. to 142 in. (0.5% to 0.25%). 2. 3/4" to 11" crushed strxe cr wad% gravel aggz:eqate- 3. 4 minim n lateral di.a Teter. 4. 2" mini = ate over lateral.. .5. 6" minimm aggregate urr-r lateral. 6. Ub atted building paper Ter 2" cf sbzw over aggrE�te. 6" minimm, 12" rmximm Earth badsfill. 8. Overfill to allcw fcr settling, 4" -6 ". 9. 2'minizrLm from trer� bottom to water- 5ft.gra3e 10. 5'min.h= t mmh bottan to #=vices 7 ft. gmh. 11. Mimc:h gzcinx3:min.610.C.(24 "tnmnch). 12. . UMMSCted lateral a-Os mist be plujgEl. 13. Fill - 2:1 slq:es min. 10' be2ad trey . dEPth:3Pmax.aer rock +;21max.cver Hater Inlnle borers. PUTNAM CUUNXx 1)C:YtiiCll"ACdYl yr 1Ai:A -.Uiii ,.�. e. S . SSDS/WS PZnE,W S SHEET - D DETAILS . a. SE= TAM TES d d. WELL EEMM 1. O O,dPt- 2" below inlet 1 1. 2 2bp cf casing 18" above gra.arl. 2 N N,inimm 3" bed cf pea gruel 2 2 2 2' above F VL cr t. 3-." . .irurmsm doh aE� a�ud:.yA' . r r.. - - casing cf Hscu,ut 4. l length - minunxn twice width to maxicnm fair - 4. 1 10, nurulmxn grout totes width. 5 5. Q Qi1et 4' below O.G. Mn. 5. M Ma ru 12" air. 6 6. S Sanitary ssels 6. I Iocatim stake. 7 7. G GnrA grackd avay fine well. 7. N Nladnle - cooing - minimum 20" in shorter _ dLmmsirn. e e. CI MUN MAIN DMUS 8. R Riffle E�±t 20% cf liquid depth abom ligiid 1 1. O Overfill to allrw fcr settling: i ng: 4"-6„ level UW , b=10 ", &5',b,22"). 2 2. -: 6 6" . -12" natural sail badcfill. 9. I If le3gth G.T. 9 f - use- 2 WLL-MLt1(t-11tS. 3 3. L LY7trmted biildirrg gaper. 10. ` ` Miniinn tarn capacity 1000 cpl/3 man; 1200 4 4. " " to 11" clean gmwl cr stone. ga2/4 be3rcan:134 cf/3 bdm;161 cf/4 b1m 5 5.' M Min. 4" pa fdated pipe. 11. P Pq±altic coating frr xein6cxced. cu=ete. 6 6• P Pipe inve t 6" off bottarL 12. I Inlet tse� 16" below flow line. 7 7. 1 18" - 24" wicb trench. 13 • Q Qul-let to mMe 18" belaa flcw line. 8 8. D Dspffi te- 14 I Inlet pipe slrpe 1" per foot min. (2%) . 9 9. , S Se armtirn fron S9CS arEB 15' min. . 15. I Inlet pipe cast iron, 4'hiin. f. IITP CR JCIq= Bak IM, P,T! Iq 16. O O.itlet Pipe slope 1/8" per foot min. (A). 1 1. P PeTurable bcx cover. 17. Q Q ullad joints far sanitary tees. 2 2 ( (Xn C b. DMIKO M B7k IET M 1. Inlet kr ext min. 2" aboie cutlet invest. 2. All valets at sane elo aticn. 3. Outlets 1" to 5" above tank bottan. 4. Minimum 12" bey irrg clean sand cr pea gel. 5. Inlet baffle. 6. Mmdm n 12" cover. 7. Fen able cover fcr as Mss. 8. Smisd pipe joints (as#a.lti.c cr equal) . 9. Mcpe attlets at 1/8 inv/ft. (1 %) . cutlEt. 3.. Iatemis fly with bottom. 4. TiGht joints pipes bat em bcxLs. 1. Slcpe 1/16 in. /ft. to 142 in. (0.5% to 0.25%). 2. 3/4" to 11" crushed strxe cr wad% gravel aggz:eqate- 3. 4 minim n lateral di.a Teter. 4. 2" mini = ate over lateral.. .5. 6" minimm aggregate urr-r lateral. 6. Ub atted building paper Ter 2" cf sbzw over aggrE�te. 6" minimm, 12" rmximm Earth badsfill. 8. Overfill to allcw fcr settling, 4" -6 ". 9. 2'minizrLm from trer� bottom to water- 5ft.gra3e 10. 5'min.h= t mmh bottan to #=vices 7 ft. gmh. 11. Mimc:h gzcinx3:min.610.C.(24 "tnmnch). 12. . UMMSCted lateral a-Os mist be plujgEl. 13. Fill - 2:1 slq:es min. 10' be2ad trey . dEPth:3Pmax.aer rock +;21max.cver Hater Inlnle borers. _.,.._._ _ ." .. CONSTRUCTION NO SUBSURFACE SEWAGE DISPOSAL SYSTEMS & WELL WATER SUPPLIES SERVING SINGLE FAMILY RESIDENCES Basic Required Notes 1. All trees within 10 feet of the proposed SSDS shall be removed." 2.. SSDS to be inspected by the design engineer /architect and the Putnam County Health Department after construction and prior to backfill. 3. No trucks, machinery, building materials, nor excavated earth shall be allowed in the sewage disposal area. Construction of SSDS to be in accordance with these plans, any revisions thereto, and the rules and regulations of the permit issuing governmental agency. 4. Minimum well yield of 5 gpm is required. Yields less than 5 gp. will be immediately reported to the Putnam County Department of Health. Notes Required When Fill Proposed 1. Fill must be allowed to stabilize for 60 to 90 days following placement' and be inspected by the Putnam County Department of Health for acceptance, prior to installation of the sewage system. Date of placement must be reported to Putnam County Department of Health. 2. 3. Run of bank fill shall be suitable for sewage absorption, be free of fines or other unsuitable material and shall have an in -place percolation rate at least equal to that in the natural soil after the required stabilization period. The engineer /architect shall, perform a final: percolation- test.-in the fill after stablilisatibri: Impervious fill, clay barrier, shall be a dense clayey soil with little or no sewage absorption capacity. / (zj ------ -COW 93._ ',F ex 41 ot, J J U! 46 %_. -A A.) /I 69AXA- IVA 4A - -- -- --------- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Address 3/ � �, �/cs6jKE2S � . \/ _ Located at (Street Cnv Sec. Block Lot_ �7ndlcate nearest cross s AeW Municipality. j �y 41M ,114 -Lt k �% , Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number' CLOCK TIME PERCOLATION PERCOLATION Run ...h-Lapse aeptn.to.water water Level No. Time. From Ground Surface in Inches. Soil Rate. Start -Stop Min. Start Stop Drog in. Min. /in.. drop Inches Inches. Inches . 3 �-� 0 5. � 1. 2 hiTy DEPT, Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. Name 0 _- S Signature_ Address SEAL THIS SPACE FOR USE BY HEALTH DEPART14ENT ONLY: he ked b O�RUFESSIQ►N Soil Rage Approved Sq. Ft /Cal. C c y