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WZLL uvrirLtiiuiv mxvAi,
* , DEPARTMENT OF HEALTH
% Division Of Environmental Health'Services
' PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STRO AOURESS: � WNW I TAX GRID NUMBER:
keks `w of o 4/ 2 — --3
WELL OWNER
NAME: ADDRESS:
-�� �, a:1 9
®PRIVATE
O PUBLIC
USE OF WELL
1- primary
2 - secondary
Ill RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HE PUMP O ABANDONED
O BUSINESS ❑ FARM O TEST/ OBSERVATION O OTHER (specify)
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED _ .S /EST. OF DAILY USAGE --Y-0-0 gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY
[SNEW'SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ��D ft.
0 r�� S
STATIC WATER LEVEL ft.
DATE MEASURED 1l
DRILLING
EQUIPMENT
❑ ROTARY 9 COMPRESSED AIR PERCUSSION O DUG
O WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING 19 -OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH -�qf— ft.
MATERIALS: I9 STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE Na ft.
JOINTS: OWELDEO 19THREADED OOTHER
DIAMETER b in.
SEAL: 9 CEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT _____I _ lb. /ft.
DRIVE SHOE CR YES 0NO_j LINER: OYES INO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
0 YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
❑ NO
'GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH h.
WELL YIELD TEST It ldetailed pumping
METHOD: 0 PUMPED tests were done is it
� �
�
COMPRESSED AIR , ormation ; attached.
O BAILED O OTHER ; ❑ YES 0 NO
�1 ELL LOG IFmore detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE.
Water
Bear•
ing
Wall
0ia'
n eter
FORMATION DESCRIPTION
Cool
ft
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAM /DOWN
YIELD
gpm.
raSul ce
v
HiMdQQ h TL,11
110
30
ICJ trl e
3�
6
�3 Lei
-4- a 11
At
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? ❑ YES O NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAT,.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME'7,pa��. DATE
ADDRESS e�— SIGNATURE
CI:A,vv(
3 /89 1 ' '
A
FUI't td CaNITZ DE?PXM r OF IMV TH
DIWSZON OF AFALTH SERVIMS
owner or Purchaser of Bui].ding
Section Blor�c y SOt
A
Building Constxuoted by
location - Street.) � /
.tea 11 Q.` .-
Muna.cipal.ity ,
Bui.l.ding Type
Subdi.vi ion Nam
Subdivision Lot 7 '
C-UPAA OF SUBSURFACE S�V-,GP- DISPOSAL SYS'I I
o
T. represent that X am wholly and corm pletel.y resptDnsi.ble for the loca -Sion,
wor_lwe lsllip, natcri_aj, construction and drainage of the sewage disposal systen
serving the above descz:ib=.d pzope"+ty, and, that it has-been constructed as shown on
the approved plan. or approved amene nent thereto, a.nd ' in accordance with. the
stanaarcls, rules and regulations of the :Putnam County Dent of Eealth ' aria'.:;.',
,hereby razxznte_ to the c r.,mer, his suocessoa:s, heirs or assigns, to place in 50
operating condition any part of said system constructed by me which fails to
opb..xate for a pei:iod of two ycaxs iiTmc lately following the date of approval: of the
"Certificate of Construction n. Comol,iance" for the serge disposal system, or any .r
xepaizs reds by me to such system, except where the failure to operate properly is,
caused by the wxlIful. or negli.gcnt act of the occupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the detemaLmtion of
the Director. of the Division of Envixor4-c.ntal Bealth Services of the Putnam Country
Depazt.r.ent o£' Health as to �,he'cher or no. the failure of . Ube systmn to operate was
us by the willful or reg t occupant of the building utilizing.
Uie system.
Dated this _ day of -t br or' 19 BLS Signature
Title
�r_ Conti e x (annex') - Signature
Corporation tanra (it Corp.)
Co ratio Na-ae (if Corp.) 3 LA e-,=Z), a,/
g
Mdress A), y. ion 7'
rev. 5/85
m�C
t eLF-PHONE # (914) 431-1696tFAX # (914) 431 .1 W7
ENVIRONtAENTAL LABORATORY APPROVAL PROGRAM CERTIFICATE # 10 189
BACTERIOLOGICA0 'FXA-AWATIOX OF WATZr
FORWARD REPORT TO: (PLEASE PRINT)
7:7
TYPE OF FACILITY;
❑
PUBLIC WATER SUPPLY
PRIVATE RESIDENP E
STREET ADDRESS
WASTEWATER TREATMENT FACILITY
I/-. !"!Y ❑ BEACH
CITY STATE ZIP
❑ OTHER.
FACILITY NAME: tZa km_cnli TOWN, PHONE#
SAMPLING POINT 0- MONITORING SAMPL ,
CHECK, SAIVIPLE7'n�
SOURCE-. 01 "DRINKING WATER; ❑ SURFACE WATER; ❑ WASTE WATER; ❑ OTHER:
Q FREE
—,--PPM U COMSINED)
TREATMENT; 13 CHLORINATED. ( OTHER;
❑ TOTAL s CJ QCHD PERSON NEIJF"4l
COLLECTED BY: TITLE: b"&ON.DCHO PERSONNI
WR I Q ,Jmmri-mw I Imc via%.Clvr "J MAI; I%jtU I MAAffilrdrU mcilvm I Cu
YE-Sl NO 3129-,�(67
Ll A m k",
AM , (731 ES1 122 9
4fM ) rl NQ I 3 f r. 5
rl M FT MPN TOTAL COLIFORM COUNT
—PER'-100,Mi
❑ MFT qMPN FECAL COLI FORM COUNT
PE-Aloo Ml
❑ m Fir FECAL STRtP, COUNT
PER"100,11MI.
13 HETEROTROPHIC PLATE.COUNT PER<i ML ?:
El COLI POSITIVE NEGATIVE ❑ misc.
THESE RESULTS INDICATE THAT THE WATER SAMPLE DID
❑ DID NOT ;' .
fR DRINKING
MEET SATISFACTORY SANITARY QUALITY FOR Cl SWIMMING
❑ WASTEWATER EFFLUENT
WHEN THE SAMPLE WAS COLLECTED. FOR
INFORMATION CONCERNING, , UNSATISFACTORY SAMPLES
PLEASE CALLTHE HEALTH DEPARTMENT AT
— -CuATpKR C-0-py
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL (`fIT DT. DGQ
glw-A
DYT K
LOCATION
e Street Iddas
ow -.(
Village/City
Tax Grid Numb
b
C12 3 1-
WELL OWNER
Name
S
Ma' ling
Address
�
rivate
10703 ® Public
SE OF WELL
- primary
2 - secondary
&RESIDENTIAL
® BUSINESS
® INDUSTRIAL
0PUBLIC SUPPLY QAIR /COND /HEAT PUMP 13 ABANDONED
0 FARM 0 TEST /OBSERVATION 0 OTHER (specify
13 INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
gpm /#
PEOPLE SERVED_ /EST. OF DAILY USAGE (000 ��1
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY
9NEW SUPPLY NEW DWELLING
0 TEST /OBSERVATION
® DEEPEN EXISTING WELL
®•ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
FELL TYPE
oDRILLED
®DRIVEN
[]DUG
®GRAVEL
0OTHER
IS CELL SITE SUBJECT TO FLOODING? YES �NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No!
STATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAE OF PUBLIC WATER SUPPLY: 011 TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
7-T Aq SON SEPARATE SHEET
(d te) 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
thirty (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 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.
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 such manner as not to degrade or otherwi contaminate surface or groundwater.
PJ
Date of Issue:_ 19-�,(� I& /®
Date of Expiration 19 b Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH
- DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY &
SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET for CONSTRUCTI PERMIT ,y
NAME OF OWNER $71 (mil STREET LOCA ON -� .� �A
BY 4Z
d ^ TAX MAP # 2 3y
MENTS.
DISCHARGE (OK)
ERMIT APPLICATION.
m PERC & DEEP HOLES LOCATED
C -1
Jm
m REPRESENTATIVE OF PRIMARY AND EXPANSION
ELL PERMIT; PWS LETTER
m EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
NGINEERS AUTHORIZATION
DESIGN DATA SHEET(DDS)
PUMPED PIT & D BOX SHOWN & DETAILED
OUSE - NO. OF BEDROOMS
DEEP HOLE LOG
QJ CONSISTENT PERC RESULTS (3)
ELLS & SSDS 'S W/IN 200 FT. OF PROPOSED SYSTEM
m PERC HOLE DEPTH
ROPERTY METES & BOUNDS
INO
m CORPORATE RESOLUTION
OUSE SETBACK NECESSARY (TIGHT LOT)
m PLANS THREE SETS
OUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE
M HOUSE PLANS TWO SETS.
BENDS; MAX. BENDS 45 W /CLEANOUT
-
m VARIANCE REQUEST
FILL SYSTEMS
GENERAL
CLAYBARRIER
10 FT HORIZONTAL: SLOPE 3:1 TO GRADE
LEGAL SUBDIVISION
m SUBDIVISION APPROVAL CHECKED
FILL SPECS
CIS PERC RATE
DEPTH GAUGES
CI] FILL REQUIRED
FILL PROFILE & DIMENSIONS
IT]
CURTAIN DRAIN REQUIRED =STANDPIPES
VOLUME
EX- APPROVAL SSDS ADJ. LOTS
TRENCH t�
LF TRENCH PROVIDED a)?i,�
WETLAND (TOWN/DEC PERMIT R & D)
60 FT MAX
DATA ON DDS PLANS & PERMIT SAME
PARALLEL TO CONTOURS
PRE- 1969 -NEIGHBOR NOTIFIFICATION
CI] LETTER BI/ZBA
100% EXPANSION PROVIDED
M 100 YR. FLOOD ELEVATION
SEPARATION DISTANCES SPECIFIED ON PLAN
REOUIRED DETAILS ON PLANS
FIELDS
,
10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL
:SEWAGE SYSTEM PLAN -'(NORTH ARROW)
m SSDS PROFILE m
20' TO FOUNDATION WALLS
HYDRAULIC GRAVITY FLOW
El D/ J BOX m TRENCH/GALLEY m P- DETAILS
100 TO WELL, 200' IN D.L.O.D., 150' PITS
PIT
CI7 SEPTIC TANK -SIZE, DETAIL
100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
TO
m WELL DETAIL, SERVICE LINE IF OVER
50' CATCH BASIN, 35' STORMDRAIN, PIPED WATER
CD CONSTRUCTION NOTES (GRINDER RATE)
. 10' TO WATERLINE (PITS -20')
M DESIGN DATA: PERC AND DEEP RESULTS
50' INTERMITTENT DRAINAGE COURSE
200 FT. RESERVOIR, ETCH 150 FT. GALLEY SYSTEMS
C� TWO -FOOT CONTOURS EXISTING & PROPOSED
SEPTIC TANKS
CD DRIVEWAY & SLOPES CUT
I O' FROM FOUNDATION; 50' TO WELL
CD FOOTING /GUTTER/CURTAIN DRAINS
WELLS
❑� 15' WELL TO P.L.
COMMENTS:
IE
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property of_
Located at
Date - -
i m o nck o
(T) A Section 2 Block 3
Subdivision of — /tlo„
Subdv. Lot Filed Map
Lot 3�
Date
Gentlemen:
This letter .is to authorize J?a r V,-
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.al1 necessary papers on my behalf. in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education. Lazar, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
Signed /ti�,
Countersigned: // OA �wner of Property
AddrAss
Address Q,;1 own Toin
Telephone
Telephone
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
August 17, 1994
Harry Nichols
Laurent Enginee'ri'ng Associates
Millbrook Office Centre
Route 22 & Milltown Road
Brewster, NY 10509
JOHN KARELL Jr.. P.E. M S.
Public Health Director
Re: Proposed SSDS: Raimondo
Peekskill Hollow Road
(T) Putnam Valley
Dear Mr. Nicholls:
Review of plans and other supporting documents submitted at this time relative to
the above- captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands
regulations. You should contact local wetlands officials in this regard."
1. Engineer's authorization form has not been completed (enclosed). Please note
filed map'number and date of approval.
2. Current codes require the minimum of one deep test hole in the primary and
expansion SSDS area. Therefore, a deep test hole is required in the primary
SSDS area.
3. Roof and gutter drain is-to be located, ithe minimum of 10 feet from edge of
trench.
4. Please notelproposed four bedroom house design flow is for three bedroom.
Revise accordingly.
i
Upon Receipt of a submission, revised to reflect the above comments, this
application will be considered further.
Ver rely yours,
/ � V
Robert Morris
Public Health Engineer
RM/jp
�v
1 '
Rev. 3186 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
\ ' + Engineer Must Provide �/' 7 • . �•
Q J
P.C.H.D. Permit #_
Located at / "R'i'tes
r
w.er /applicant Name
MaWng Address �.
Separate Sewerage System built by
Consisting of
IMM
FOR SEWAGE DISPOSAL
L
Septic Tank and
z
Town or VWagq
Talc Map— /Block 3 Lot � 9
Subdivision Name ` L`'1. 4E- Sabdv. Lot q Z.
Date Permit Issued a `1 % " 9 t
i
- r
Water Supply: Public Supply From Address
1
ors Prly Supply Drmed by c' f Address
r
BuIlding Type Y- Has Erosion Control Been Completed' �-
Number of Bedrooms 3 Has Garbage Grinder Been Installed?
Other Requirements
I certify that the system(s) as listed serving the above premises were
of which are attached), and in accordance with the standards, rules and
Putnam County Department Of Health.
Date 3 `l& ji Certified by-
Address
— t_&Mf -
essentially as shown on t plans of the completed work ( copies
in accordance with the led lan, d the permit issued by the
G/� P,E.� R.A.
LIcenN No,
Any person occupying premises served, by the above systern(s) shall promptly take such action as may be necessary to Secure the correction of any unenitary
conditions resulting from such usage. Approval of the separate sewerage system shill become null and void as soon as a pub,:: sanitary ewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
WNW to modification or change when, in the Judgment of the Commissi su t1^re cation, modification or change Is necessary,
oae
� Tlta
pU2W 11[ COUNTY DBPARTMIM OF HEALTH I to PkavNe Paaok 0
DhYw d �nlarmeal/d Harkh Seat foaa. Card. N.Y.1�U a. E MUANC
Pak / /
/ / / 7
Pll U= FOR WWAI
i� is•�i'/l�
1 ao
i Taw. a< vNe o /
Tam Map. -�-= —Block t°a
RAnewd_O Revide. O
Date of Previous Ainoffovd
Tow. `I i1 K Q r i Y np / Q 7 0 3
nalltsrlt T ,N � p C ` I P cal -1:' a 1 Lot Area � Fm Sect&. Only Depth vebtoe
Nosier d Beiaeaaa I Design Flow G PD.--600 PCHD Noll�lb. & Rootmd When Fm & oesapMbd
SapaeaM S.weeme Sighs• to essis sit OU 0 S yaek 3
To be owishmelod by
Waar S"*. -Pile SW* Feu Address
On__Z__Plivab Sup* DAW by Ad bvao
Other Regdeaiaw
1 represent'.thal 1 am wholly and completely responsible for the design and location of the proposed systom(s)1 1) that the saparate swage disposal system
above described will be constructed as shown On the approval amendment there to and in accordance with the standards, rules and regulations
o
County Department Of Health. and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the COmmISSloner of MOalthwill
be submpted to the Department, lands written guarantee will be furnished the owner, his successor, heirs or asaigns by the builder, that Yid bulklw will
aNte in good operating condition, airy art of said sewage disposal system during the period of two (2) y Immediately following thedate Of the NOW
aria of the ap "Of of the Certificate Of Construction Compllence of t e iginal system or any repairs t ate; 2 that the dr0led well described adOwe
wo be locete4 as shown on the approved plan and that said well will d• Instal in accordance with t sta s, ru S rqu ns of the Putnam
ce ,nty MITEA- Health.
Date . I i Signed /� ` p P.E. R:A.
AA: li �,. .Ir O pia-. _a l A. (P� 11 Pi 0V 0 License No '561-2-4
APPROVED FOR CONSTRUCTI
revocable for MISS Or may be an
+is approval expires two years rom 1ne u ■.e .1
or modified when considereO n4pssary by the
----. -. 114Ln onitAA e. and /Or
unless construction of the building he been undertaken and is
missioner of Health. Any charge or alteration of construction
to water supply only. , ® l
2.
4.
6.
7.
9.
10.
11.
12.
13.
14.
15.
:6.
'7.
PYJTN',A.� COYJ'N'��" ]�>✓P,'A.R'rL��N2' O)F' ��.A.x.T'X -3C
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
Name and Address 'of Applicant: t �l w10>1 �o
(03 k
04 ( 07 0 3
Name of Project:) �6',a iJ.SJ SS/ 3.•_. Location �/,V/C•
r,
Project Engineer: tiGcrt) �� �+ ��a /S Tr. 5. Address: N_1�((b,^c,o Qg;( -R- %Kt!,e
�kP 224 M; �idvKtn 42i {.
License Number: '56124 Phone:
TIp, of Pro ect: .: , _•. _
✓ Private /Resi.dential . Food Service, : ....Comme.rcial
Apartments' Institutional Hobile Home Park
Office Building Realty Subdivision Other (speci`fy)
Is this project subject*to State Environmental-Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt _ /
Type II. Unlisted.
mental Impact Statement (DEIS) required? ............. N 0
Is a Drart Environ .. •
Has DEIS been comp',)
eyed and found acceptable by Lead Agency? tiA
Name of Lead Agency
Is this project in'an area under the control of -local planning, zoning,
or other officials, ordinances? ............. "0
If so, have plans been.submitted to such. authorsti es? ....................... IV
Has preliminary approval been granted by such authorities? Date Granted:
Type of Sewage Disposal: System Discharge ..... .^' Surface Water .Ground Waters
If surface water discharge, what is the stream class designation ?........ V
Waters index number,(surface) .... ...... ............................... IU A
Is project located near a public water supply system? .................. N� I
S. If yes, name of water supply Distance to water supply,
9. Is project site near a public sewage collection'or disposal system ?:.... 00
fl. Name of sewage system h Distance'to sewage system
1. Date observed:
23. Name of Health Inspector:
6�
0
�- Project design flow ,(gallons per day)..........,......... .............. '
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.._ l p
26. Has SPDES Application been submitted to local DEC Office? ...............
27. Is any portion of this project located within a designated Town or State
wetland? .................................: ............................... (V 0
28. wetland ID Number .. .................... ...............................
29. -Is wetland Permit - required?. .............. ...............................
Has application been made to Town or Local DEC Office? ...............`...
Na •
30. Does project require a DEC Stream Disturbance Permit? ...................
31. Is or was 'project site used for agricultural activity involving application` .
of pesticideq- to orchards or other crops, solid or hazardous Haste disposal;``` "
landf:illing, sludge application or industrial activity? ........ YES'or NO
32. Is project located-within 1 -,000•feet of existence of abandoned.landfill,
hazardous waste site, salt stockpile, landfill, sludge.disposal site or
any other potential known•source of contamination? .....'.........YES or N0 b'
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ....
34. Are corrmunity water, sewer facilities planned to be developed within 15 years? U 11-Jn
35. Are any sewage disposal areas in excess of 15ro slope? ..........................
36. Tax Map ID dumber ......................... ...............................
37. Approved Plans are to••be: returned to: ................. • Applicant Engineer
If the application is signed by a person other than the appl.icant shown in Item.1, the.
application must be-accompanied by y-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 knorrledse and belief. False staten -ents made
herein are punishable as a Class A Xisdea- reanor pur uent to Section 210.45 of
the Pena 1 Law. . ! � I
;IGNATURES & OFFICIAL TITLES:
M 1, ro e
,AILING ADDRESS: S:
Ed MA
• • a r r is v 011 y 1 fib: 66-120151906204P
DESIGN IAA SLMM- SUBSUFACE SEKAGE- DISPOSAL SYSTkM FILE NO.
'
omier Q r�" ' i. G : JV� [� Address �,,
' a 03
ibcated a' t (Street), Sec. L(2 Block
3 Lot
(indicate nearest cross street)'
nmicipaLity Watershed
CC ra ki
SOIL PERM=CN••73S`.0 DATA RFXXT= TO BE .SUB'.dI= WITH APPLICATIONS
Date of Pre- Soaking. J - 26 -13 Date of Percolation Test
ROLE.
A
NU MM C= TIMS PERCOLATION
P=LMCN
Run Elapse to Water )From Water Level
_Depth
No.. Turn Ground Surfac6 In Inches
•Soi.l, gate •.
Staff -Stop Min : Start Shop Drop In
Min/7n Drop
°'Inches Incises inches
C7
3 g• -3 <1-3 1
6-0
2 2t S6 =Z`f '= 27
.3 2!! 57- 3.2 - 27 24 27: 3 if
4 ?� 2 S' 3= 2 - 2-1 2q `` 0 �r ac
�1�0 I .
5
1
2
3
4
NOMS: 1... Tests to be repeated'. at same depth until apprcximately equal soil rates,
are obtained .at each percolation test hole. • AU data • to' be submitUd '.
for preview.
2. : Depth r r_a ements. to be made fran top of hole.
DFSCRII)IION OF SOILS ENMUNTERED IN TEST HOTS
DEPM HOLE NO. HOLE NO. HOLE NO.
21
3,
5, C OctWl
61 A•
71
9'
10'
11'
121.
13'
14'
INDICATE LEVEL, AT WHICH GR UNI7rKA= IS ENCOUNTERED
INDICATE LEVEL-. TO WHICH HATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MP.DEiBY:
DATE.
C DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided.
No. of Bedreans Septic Tank Capacity l0 0D gals. 5'y C'ov�C• .
Absorption Area*Provided By 3 E L.F. x 24" width trench
Other
IF N
Signature
Address M�1�brQo�Ge 0��ce. �p�� -re SEAL
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THIS SPACE FOR USE BY HEALTH DE.PARMENB ONLY.-
Soil Rate Approved sgaft %- Checked by
' Date