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WELL COMPLETION REPORT
Office Use Only
DEPARTMENT OF HEALTH
Division Of.Environmental Health Services
W Y�4 PUTNAM COUNTY DEPARTMENT OF HEALTH
ST -T AOORESS:. W IL . Y TAX GRID NUMBER: � 3
WELL LOCATION _ 23 a em7'
WELL OWNER NA , ORIE FjoappBIVATE
UBLIC
USE OF WELL Ia RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
1 - primary ❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
2 -,secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED 3 / EST. OF DAILY USAGE
gal.
REASON FOR ANEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ -TEST/OBSERVATION
DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH VOT ft. STATIC WATER LEVEL ft. DATE MEASURED
DRILLING J21- ROTARY ❑ COMPRESSED. AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WEI,L.TYPE.. _. OCENED D OPEN ENO CASING 0 OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH Q'P tL MATERIALS: ; STEEL ❑ PLASTIC O OTHER
CASING LENGTH .BELOW GRADE "'� ft. JOINTS:, ❑WELDED THREADED ❑OTHER
DETAILS DIAMETER � in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE I&OTHER
WEIGHT PER FOOT 1r SHOE:ZIYES ❑ NO LINER: 0YES ONO
SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED?
DETAILS FIRST ❑ YES, ❑ NO
SECOND HOURS
GRAVEL PACK ❑ YES ' GRAVEL DIAMETER TOP BOTTOM
❑ NO SIZE OF PACK in. DEPTH ft. DEPTH It.
WELL YIELD TEST it detailed pumping WELL LOG
It more detailed formation descriptions or sieve analyses
are available. please attach.
METHOD: ❑ PUMPED tests were done is in-
DEPTH FROM Water Well
O COMPRESSED AIR ,formation attached? SURFACE eear- Dia- FORMATION OESCRIPTION cote
❑ BAILED .❑ OTHER ❑ YES, ❑• NO }t. tt. ing Metter
WELL DEPTH DURATION DRAWOOWN YIELD Surrtace
ft. hr. min. It. gym.
f--
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES ❑ NO
ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK: TYPE
_ PUMP 1NFOH111ATIOH cApacl "rY.._ - - :� -� .. - .... GAL' /r-a..
TYPE CAPACITY WELL DRILLER NAM
.ate �0
MAKER DEPTH 390 ADORE Z'34e- '1��'?' 1GrMTURE
MODEL - a-- VOLTAGEa13 HP 3 "^
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PUTNAM COUNTY DE:
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HOJUSE PLANS JAPPROVE OR
-
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PUTNAM COUNTY DEPAC14M OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
0, c�
(Name of Owner)
,REVIEW „SHEET •- :..CONSTRUCTION - •PERMIT
DATE REVI
BY:
( treet Location)
DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
30” Perc Hole
Other
(3)
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 /Gutter Curtain Drains
Perc &.Deep Holes Located
Representative of Sewage &,Expansion.Area
E) pansion-Area-, shown; gravity- flo,,4, suit: -- size- If Pumped Pit & D Box Shown & Detailed
House - No. 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 45° 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 (inc. expan)
15' to Drains- Curtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' from Foundation
50' to Well
15' Well to PL
ORAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of
a / �► OR
r
Located at 1.1 O G' �y
.7
(T) ri,r? /O- e . Section �. Block Lot 1
Subdivision of i % G jG =i?Cy
Subdv. Lot # Filed Map # Date.
Gentlemen:
This letter is to authorize r 0 ° -6
a duly licensed professional engineer or registerred architect
(Indicate
to apply for a Construction Permit for a separate sewage system,. to
serve the above noted property in ac_eordance with the standards, rules
or regulations as promulagat.ed 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 systems in conformity with the provisions of Article.145+or r _.
147, Education Law, the Public,Health Law, and the Putnam County Sani
tary Code.
Counter
21
P.E.,
dress
�� e
Very truly yours
s
Signed'
Owne f Property
C 11:1r
Address
1-0 15
To
/ Telephone
Telephone
C
4
DAVID D. 'BRIJEN
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
'October 30, 1986
Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, New York 10598
Dear Mr. Sullivan:.
• a
I
JOHN SIMMONS. M.D.
Deputy Commissioner
Re: Karabinos
Bell Hollow Road
(T) Putnam Valley
TM .23 -4 -1.3
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:
1. due to age of subdivision, -new deep holes and
tests are required. Please.advise this office
deep holes are excavated so that an inspection
scheduled.
�' +2: locafe iweTl - arid septic "'of adjacent ic�t to'-sout`
percolation
when new
may be
h...oh...p.Ian
Upon receipt of a submission, revised to reflect the above
comments, this application will be considered further.
` Ver '' tr� X it yours,
Anne tner
AB:pt Asst. Public Health Engineer
cc:AB
JK
File
I
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) .225 -3641
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225-3641
-- - - -.... - APPLICATION TO CONSTRUCT A WATER WELL
........... _......w _ PnCHD PERMIT #T :z,
WELL LOCATION
Street Address
f3c7% ��t�/ ` �..
Town Village City Tax Grid Numb r
��� "� �z� a-3- 4°- j]- `
WELL OWNER
/�a � J Address �q P,,y�' OPrivate
Celllloe 2" .ZdGv � '� -ld'e° �lO Public
USE OF WELL
1 - primary
2 - secondary
SIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
® INDUSTRIAL M INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /4�
PEOPLE SERVED !� /EST. OF DAILY USAGE0dIr gal
REASON FOR
DRILLING
UNEW SUPPLY
OREPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
M<RILLED
ODRIVEN
ODUG OGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING?
YES d""' NO
IF WELL IS LOCATED IN, A REALTY SUBDIVISION, NAME OF SUBDIVISION: _57e_A' rr_-�;e,v
Lot No.
WATER WELL CONTRACTOR: Name �� >`�'� Address: /517 ar'
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES NO
NAME OF PUBLIC WATER SUPPLY:-,.- TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST - WATER. MAIN.:____.—
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION ON SEPARATE SHEET
(date)
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.
2.
3.
Date of
Date of
Permit
8/86
Pump the well until the water is clear.
Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
Submit a Well Completion Report on a form pr vided by the Putnam County
Health D partment.
LJ6_Ax `
Issue: 19 U
h A1"),4_.
Expiration: 19 51b rmit Issu g ff ial
is Non - Transferrable
PMk,1 COUMY DEPARrI:T -UM OF HEALTH
_.... _ ........ "OM8100_0F ENVIROyNfLdV`ML -HEALTH SERVICES
Owner or Purchaser of Building Section Block Lot
Building Constructed by ^i t �;,:
Location - Street Subdivision Name
Municipality Subdivision Lot #
Building Type .
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYS`I A
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 -e "feriod of trio years :iirniEd� dtely, foilcxaing "the date of approval of., ''the--t =
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by me 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 syst,an.
The undersigned further agrees to accept as conclusive the del:ermdnation 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 TAN�6a Y19�
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address .
rev. 9/85
Mk
Signature �--�
Title
Corporation Name (if Corp.)
Address
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DEPARTMENT OF HEALTH
Division , Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
BRUCE R FOLEY• R.S.
Acting Public ,Health Director
Re: aQOe,`�c��r��
'Residence
Tax -Map , 1
Tovn'PLAV'\Qr`^ Va Ut�y
Gentlemen:
According to records maintained by the Town, the above noted dwelling
S
IS NOT
t .
in compliance Nrith Town code and the total number of bedrooms on record
is
This information has been obtained from:.
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:'"
OTHER
a
DEPARTMENT OF HEALTH
Division , Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
BRUCE R FOLEY• R.S.
Acting Public ,Health Director
Re: aQOe,`�c��r��
'Residence
Tax -Map , 1
Tovn'PLAV'\Qr`^ Va Ut�y
Gentlemen:
According to records maintained by the Town, the above noted dwelling
S
IS NOT
t .
in compliance Nrith Town code and the total number of bedrooms on record
is
This information has been obtained from:.
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:'"
OTHER
DEPARTMENT OF HEALTH
Division of Environntal Health Se
me rvices
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fa~ (914) 278-7921
BRUCE R FOLEY
Public Health Director
PROPOSED ADDITION APPLICATION (RESIDENTIAL OtiTLY)
STREET t A( Q10-W k~ OT
NAME PHONE SP— 8 53WCHD r ID ° �b
MAILLtiGADDRESS' a.00 �% e11 ��tt ` , TL4T
e'er loco � L
DESCRIPTION OF ADDITION- 4,
NUMBER OF EXISTING BEDROOI•IS _3 . PROPOSED. n .OF BEDROO NMS
(FROM, CERT. OF OCCUPANCY OR
CERTIFICATION' FROM BUMMING NSPECTOR)
*Any addition which is considered a bedroom requires formal approval of plans (Construction
Permit).prepared by a Professional Engineer or Registered Architect in accordance with
applicable sections of the Putnam County Sanitary Code.
t o 79
Please submit this form and the following to Putnam County Health Dept., 4 Geneva Rd.,
Brewster, NY 1A509, Phone 278 -6130.
VCertified check or money order for $100.00 c 0 3 8 4
Sketches of existing floor plan (drawn to scale, all living area including basement)
# Non- professional sketches are acceptable _
/4Copy TvY6 sets of proposed floor plan (drawn to scale, with name, street, and tax map of survey showing well and septic location, to the best of your knowledge. Include date
of installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
V5. Copy of Cert. of Occupancy from To of Ce-1'trflea from B bu i ldiWOept: witflegal-
(-:Ve-droe om c tof d-w—c. rng
OFFICE USE
Comments
'b
r/.
f
i
DEPARTMENT OF HEALTH
Division of Environntal Health Se
me rvices
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fa~ (914) 278-7921
BRUCE R FOLEY
Public Health Director
PROPOSED ADDITION APPLICATION (RESIDENTIAL OtiTLY)
STREET t A( Q10-W k~ OT
NAME PHONE SP— 8 53WCHD r ID ° �b
MAILLtiGADDRESS' a.00 �% e11 ��tt ` , TL4T
e'er loco � L
DESCRIPTION OF ADDITION- 4,
NUMBER OF EXISTING BEDROOI•IS _3 . PROPOSED. n .OF BEDROO NMS
(FROM, CERT. OF OCCUPANCY OR
CERTIFICATION' FROM BUMMING NSPECTOR)
*Any addition which is considered a bedroom requires formal approval of plans (Construction
Permit).prepared by a Professional Engineer or Registered Architect in accordance with
applicable sections of the Putnam County Sanitary Code.
t o 79
Please submit this form and the following to Putnam County Health Dept., 4 Geneva Rd.,
Brewster, NY 1A509, Phone 278 -6130.
VCertified check or money order for $100.00 c 0 3 8 4
Sketches of existing floor plan (drawn to scale, all living area including basement)
# Non- professional sketches are acceptable _
/4Copy TvY6 sets of proposed floor plan (drawn to scale, with name, street, and tax map of survey showing well and septic location, to the best of your knowledge. Include date
of installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
V5. Copy of Cert. of Occupancy from To of Ce-1'trflea from B bu i ldiWOept: witflegal-
(-:Ve-droe om c tof d-w—c. rng
OFFICE USE
Comments
^:
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Ar C7 19 ccJ! i'ILIS5 'C ^: 'F.TT38rit
W, )J P iLATt1 1 -i, s _ to _ ztt of ti _.1 :h.
.1t°= �S
paffi uom►W y n'T OT r6—M
Division of Environmental Health Servicb,
A-S 3 L, I L7-
ipproved as noted for conformance with
applicable Pules and Regulations of the
PuttnaD County jiq h Department. l/
� �� 1
717��e_
Ile, j
PUTNAM COUNTY DEPARTMENT OF HEALTH eer to Provide Permit #
YQev. _ 3186 Division of Environmental Health Services, Carmel, N.Y. 10512 on CERTIFICATE OF COMPLIANCE x
Permit # V
ONSTRIICTION//��PERMPP FOR SEWAGE DISPOSAL SYSTEM J J � 7 �� /��
/i� ✓� ' / Jl �% �✓B o 4 _ _ _ / Town or Village / . . .
..... ted`at ac �w
S bdlvision Name ✓L %iS .S t� Sabd. Lot N Ta: Map a Block LoL /••.�
w� : / / Renewel_O Revision LE"
Owner /Applicant Name 11 Date of Previous Approval
Melling Address
���t"r ✓�'r"e- Town Zlp,
Lot Area 3 • Jr Ac , Fill =Nodfleadon Depth �completed
Ba�dlog. Pe 6 d Cl s Required Wher_F
Number of Bedrooms Design`Flow G /P /D
Separate Sewerage System to consist of �1 Gallon Septic Tank aa�
To be constructed by Address
Water Supply: Pdblic Supply From Address
or:._._1.— _Private Supply Drilled by - // ----Address
/ �Lv Other Requirements
I represent that I am wholly and completely responsible for the design and location of the
above described will be constructed as shown on the approved amendment there to and in a
County Department of Health, and that on completion thereof a "Certificate of Constr
be submitted to the Department, and a written guarantee will be furnished the owner,
place in good operating condition any part of said sewage disposal system during th
once of the approval of the Certificate of Construction Compliance of the original s
will be located as shown on the approved plan and that said well will be installed in accor
County Department of Health.
>
Cf Signed 4414-
% .^%
Date ia
APPROVED FOR CONSTRUCTION: T s approval expir _ year from the
revocable for cause or may be amends or modified when
side essary
requires new— �per�mit. A(p,(proved for disposal of dome wage
Date By
R ev. 3;86
Located
he
that the separate sewage disposal system
ds, rules an regu a ons o e Putnam
ory to the Commissioner of Healthwill FIL by the builder,
Inm lately foder, that said builder will
following thedate of the Issu-
e; 2) at the drilled well described above
t&ifs nd regua ons of the Putnam
R.A.
%S
xLicense No y
elbuilding has been undertaken and is
Change Or alteration of construction
_ Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512 Q
_ Engineer Mast Provide l/' ! 2
_ ... _ P:C.H.D. Permit N =—� =— —
OF CONSTRUCTION COMPLIANCE FOR SEWAGE
SYSTEM
Owner /applicant Name Ify I " 7 Formerly
Mailing Address 2 O S e'l 1 Kc r c b 1 to y S Zip iv 5 7 rj
Town or V e
Tax Map �3 BlockLot 3
Rip sZrs!s1, --
Subdivision Name Subdv. Lot N
Date Permit Issued -Pt-C. • % 9 7d
Separate Sewerage System built by Ow" Address
Consisting of Coo Gallon Septic Tank and J U O t'✓ J e• h'r G
Water Supply: Public Supply From •, Address
ors kf" Private Supply Drilled by ,v C"� s- sr'hAddrese 3�ir>, ✓ / }` j� i/ ..
Building Type �' cltt 10 5-41as Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed? N
Other Requirements –� A�� OF Nflti Y
I certify hat the a stem(s) as listed serving the above
Y Y 9 premises were constructed set g lens of the completed work (copies
of which are attached), and in accordance with the standards, rules and regulation in dance wi fi d plan, and the permit issued by the
Putnam County Department Of Health.
Date �Z' / C rtified Oy P.E. �cR.A.
Address i _ License NoA, a �r
Any person occupying premises served by the ove system(s) shall promptly take such be n a ure the correction of any unsanitary
conditions resulting from such usage. Ap oval of the separate sewerage system shall 18 as a publ;: unitary ewer becomes
available and the approval of the private water supply shall become null and void When a comes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner of Health, odlfieatlon or change Is necessary.
�yl
i
RONALD L. KARABINOS 1258
CELINE M..KARABINOS
200 BELL HOLLOW RD.
PUTNAM VALLEY, NY 10579 19
1-108/280
Pay tot $
O der rJ
�,t101 L I Dollars
PEEK K L OUFFICE
BMATF311lAS 8W113LAfM® 03Ah.PJ00, m.m.
PEEKSKILL, NEW YORK 10566
For
000021300108 L1a48B747953110 1258
DESIGN DATA SHEET- smsumCE SEWAGE DISPOSAL SYSTEM ''FILE ND,
Owner 17a n vleil eez Address % G'� 5 ,%�i�G • �'� %is %�GL
Located at (Street) /� �� �!i Sec. Block . Lot
(indicate nearest cross street)
Municipality Watershed
SOIL PERCOLATION TEST DATA TO BE SUBMITM WITH APPLICATIONS
Date of Pre- Soaking
Date of Percolation Test �� �"� Tom•- .
HOLE
NUIBER Q,OC:R TIME
PERCOLATION
PERCOLATION
Run Elapse
Depth to Water From
Water Level
No. Time
Ground Surface
In Inches„
Soil Rate
Start -Stop Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
te
�/ i yam I A> r'
.4.
5
_ 2i.?,/
5
1
2
3
4
5
i
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are•obtained at',:.each.percolation test hole. All data. to'be. submitUd
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
DEPTH
rl °
21
e
3'
4°
5°
6°
7'
8'
g°
10'
11°
12'
13°
14°
INDICATE LEVEL AT WHICH GROUNDNATER IS ENCOUNTERED T Ale'
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:
-- DESIGN -
Soil Rate Used %l Min /1" Drop: I I I S.D. Usable Area Provided e'0 '
No. of Bedrooms Septic Tank Capacity 45�Qd gals. Type
Absorption Area Provided By L.P. x 24" width trench
Other
0-YD;:M!21Y1 R. RMze "Inn"Mis . i'l
a. �• a• a1• �•
�• • • •
HOLE NO. /
Name Lr�v' / ®V SignatUr �pUUe,yb o ° a c
•° °
Address
THIS SP;CE FOR USE BY HEALTH DEPARTMENT ONLY: ''`'
�aQUr;�arna °`
Soil Rate Approved. sq.ft /gal. Checked by Date
PUIMM CXJNTY DEPARTKENT OF
DESIGN DATA SHEET .SUUBSUFACE SEWAGE DISPOSAL SYSTEM
FILE NO. '
Owner ZO� Address 9�
�4 /1
Ld cysr>°- %��sJ/ JJ
Located at (Street) °'f ��� Sec,.
Block Lot �'
(indicate nearest cross street)
Municipality �1 6� 'Ile
Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking /. /z� G Date of Percolation Test
HOLE
NUMBER CLOCK TIME PERCOLATION
PERCOLATION
Run Elapse. Depth to Water From Water Level
No. Time Ground Surface
In Indies. Soil Rate
Start -Stop Min. Start Stop
Drop In Min/In Drop
Inches Inches
Inches
2% -3c
3/0 % O 3a d �i" a _
4
5
3/,e / 57 ,/e yam 3cl
4_
5
,r 1
2
k7
J
4
5
NOTES: 1. Tests to be repeated'at same depth until approximately equal soil rates
are -obtained at each percolation test. hole.. All data to* be submitted. -
for review.
2. Depth measurements to be made fram top of hole.
rev. 9/85
TEST PIT DATA RDQUIM TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. / HOLE NO. HOLE NO.
G.L.
2 {/G1wj
31 �'�G✓" ea G vim% fyrac' G�ct
4°
5°
6°
7°
8° .
90
10° -
ti
12°
13'
14°
C _ b' ✓sue Cb' � � ,
INDICATE LEVEL AT WHICH GROUNMATER S `ENCOUNTERID
INDICATE LEVEL TO WHICH WATER`LEVE RISES AFTER- -BEING 1=UNTERED
DEEP HOLE OBSERVATIONS MADE BY:�cr� � � DATE:
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided ® 117e
No. of Bedrooms Septic Tank Capacity ,/O aU gals. Type�s�
Absorption Area Provided By _G'� L.F. x 24" width trench.
Other
Name _
Address
THIS SP,
61"
HEALTH
Sh
Soil Rate Approved sq.ft /gal. Checked by Date
S