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02628
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02628
PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev. 3186 blsb Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit # /
on CERTIFICATE OF COMPLIANCE -�/
CONSTRUCTION PERMIT FOR SE AGE DISPOSAL SYSTEM Permit # """CCC7»
Located at G C— C— V-<At or v v �L lT'y
ivage
Subdivision Name Ali �STA Z `ate SWA. Lot # Tax Map ! Block t Let
Owner /Applicant Name ( GJr� Ic �- Renewal ❑ Revision ❑
Date of Previous Approval E
Mailing Address ��� C� l�6 -t-,> i W e Town �tU ��� _ Zip l SSA
Building Type �a` I` Let Area S2" �`� Fill Section Only Depth Vohmte
Number of Bedrooms ,s Design Flow G /P /D (0-0 �Ap> PCHD Notification is Required When Flit Is completed
Separate Sewerage System to cons -its-t of Gallon Septic Tank and t> ��
To be rnnstru ted by 1`•" � 1>1 �Er-tA 1f'lel Addreee
Water Sapph : Pdblic Supply From Address
75 or. —,�— Private Supply Drilled by Addre��'
Other Requirements
1 represent that 1 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 any a Ions o the Putnam
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 installed in accordance with . he st rds, rules and ragu aeons of the Putnam
Catett env If Health. /�
Date '/�L Signed
�' � CJC� (,�� ( - ` A p j ���(, P.En JX R.A.�i-
Ad dress � -�1W �-f ' �' re1F- STS tJ'v —' i�.`jcense No L60<35
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issue untess construction of the building has been undertaken and is
revocable for ca se n ay be amended or modified when considered ne essay y the xpri missioner of Heal h. Any change or alteration of construction
requires ane p Emit, roved for disposal of domestic sanitary e a ,and /or ate r p nly.
Date By Title r�-✓ ` ��
PUTNAM COUNTY DEPARTMENT OF HEALTH C�V rlua {
. J�. PROOVIDE VIDE
PERMIT #PV-
_,,.�.., Division of Environmental Her /th Seryit�ea, Carmel, N. Y. -10512 BLS - 5
CERTI TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Town Pt tT► ��°i -i- y
Town er-1'V7ltaye
Located at
( (;..�.� T—> Tax Map 9 Block 1
Owner 1 t./L G>zoGt�e e / Formerly Tax Map Lot # �!o . �I subs. Lot #
Separate Sewerage System built by "Vwo -A `..0i.1% -M1 4ZT10W 1WC• Address
Consisting of ICOO Gal. Septic Tank and SIS L.F.
AgSORPTLot�l — T�RE►tCH
Other requirements
Water Supply: Public Supply From
Private Supply Drilled BY
-tom Address MAVi� ST ��'4T TL=i2SoIJ j�1 Y 1 %5 !�3
Building Type Sg 11>f -- cm— No. of Bedrooms 3 Data Permit/ Issued 5 IZ • 81
Has Erosion Control Been Completed? yES Has garbage grinder been installed? IVO
r
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health.
Date OCT 0
Address
P,E,X— R,A.
,{o. 7-6008
Any person occupying premises served by the above system(S) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from Such usage. Approval of the separate sewerage system shall become null and void as soon as a public sanitary sewer becomes
available and the approval of the private water supply shall bec7he and void when a public water Supply becomes available, Such approvals are
subject to modification or change when, In the judgment of C m stoner of Health, Such revocation, fnodificatlon or change Is necessary.
Date - v B Title
` PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit #
CONSTRU PERMIT FOR SEWAGE DISPOSAL SYSTEM
Located (A Wiccopee Road
on CERTIFICATE OF COMPLIAN
Permit a % k > r 211— /4 Y/— y zy,
Putnam Valley
Town or Village
Subdivision NII& Wiccopee Rstates ISlabd. Lot a 7 Ta. Map 19 Block 1 ____Lot 16. 7
Renewal— ❑ Revision ((j%
Owmer /Appllcamt Name Jim ('.rn('kP.r
Date of Previous Approval
Mtdung Address 244 Center Drive Town Mahopac , NY Zip 10541
Building Type 1 family residence Lot Area 8. 579 t acres Fill section Only Lj Depth ___.r.vei„mme
Number of Bedrooms 3 Design Flow G P D 600 I PCHD Notification is Required When Fill is completed
Separate Sewerage System to consist of 1009 Gallon Septic Tank amd 375 LF of 21 trench
To be constructed by to ge ' determined Address
Water Supply; Public Supply From Address
or: X Private Supply Droved by to be determine�drees
Other Re auirements 31 ROB L11. 11 Di s tr i h]at i On Box _
1 represent that 1 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 an3 regulations of e Putnarn
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Health will
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 aDDrovaI of the Certif irate 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 installed in accordance with the standards, rules and regulaTi ns of the Putnam
County Department of Health.
Date .. �o '''j . ... - -__. .. Signed (�/LL.G�- P.E..�._ R.A.
V I GnnOp
Address License No 2600.8
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been' undertaken and is'
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
requires a w permit. Approved fo disposal f domestic sanitary 4v an r private water supply only.
Date By Title_ ?�
.t
*i
I[i Y 0
WELL UUr"1rLL11UN IN%ZrUml .
DEPARTMENT OF HEALTH
Division..Of. Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
dam.. +�
= _
WELL LOCATION
STREET ADDRESS: TOwN /vll / I Y TAX GRID NUMBER:
` w
WELL OWNER
NAME C ADDRESS:
1krpBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND./HEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT _ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
VNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY D TEST / OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL .
DEPTH DATA
WELL DEPTH i� 6 ft.
STATIC WATER LEVEL �DATE
MEASURED -�-' °t F A7
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING. fD OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH ft_
MATERIALS: STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE —1-3 —ft.
JOINTS: 0 WELDED OdTHREADED ❑ OTHER
DIAMETER 7 in.
SEAL: KCEMENT GROUT O BENTONITE ❑ OTHER
WEIGHT
PER FOOT 1b./ft.
I DRIVE SHOE YES' ❑ NO
I LINER: O YES ONO
SCREEN
OIAMErER (in)
sL07 SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
O YES ONO -.
SECOND .. ^.:
s ...: .
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
70P
DEPTH tL
BOTTOht
DEPTH It.
WELL YIELD TEST If detailed pumping
MF. HOO: O PUMPED 1 tests -were done is in-
IF COMPRESSED AIR , formation attached?
O BAILED O OTHER ; YES NO
1�IELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
i�9
Well
Dia-
In
FORMATION DESCRIPTION
G70E,
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
it.
YIELD
gFm.
Surface
�}
WATER CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME DATE
ADDRESS stcft3fTURE
AM/tom / P� - -
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
W
D'
orktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights,. N. Y. LO598 {
(914)245 -3203
Director: Albert H. Aadovani M. T. (AS&) .
ellold 37 /V)
r
LAB
Date Taken: Time
Date Rc�' d : Tiai` "'
Date Reported: AUG. 0 5 198
Collected By: /w /F eAE�f
Referred By,:
Sample Location
Phone
Phone 'Samp'le Type:
Repeat Test? _ (check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER,
GENERAL BACTERIA
Standard Plate Count (CFU /1.OmL)
(Agar-Plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
_\.L Total Coliform (CFU /100mL)
Fecal. Coliform. (CFU /100mL)
Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE '(MPN-)
Total Coliform: MPN Index (per 100mL)
Fecal Coliform: MPN Index (per 100mL)
OTHER ANALYSES
REMARKS (For Laboratory Use)
.Potable
Non- potable,
STP INF
_ STP EFF
Other:
Sample Status:
- (check each)
Outgoing .
Na2'S203
Incoming
_V LE 4 0 C
_ GT 4°C'•.'
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tior of Source.
TNTC= Too Numerous.To Count
CON = Confluent ( =TNTC)
LE = Less Than or Equal to
GT = Greater Than
N/A Not Applicable
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS) (WASN'T) .(NIA.) OF A
SATISFACTORY SANITARY QUALITY ACCORDING.TO THE E YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
For Lab Use Only:
./ oo H/C, to
/X/
Albe H. Padovani, M. T.. (ASCP), Director
R
PUTNAM COUNTY DEPARIMERr OF'HEALTH
"I:rI �lrAL - - -
.. DIV t?i3�OF� °ENVIROi �`HEALTFI'SEftV.10ES :.
Owner or Purchaser of Building
Building Constructed by
W ( CGop,—=�
Location - Street
Municipality
/ �e �P_
Building Type
Section Block Lot
Subdivision Name
' ,_-r
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, const.rui ted'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 owper, his successors, heirs or as.signs,,to place in good
operating condition any part of said system constructed by me which -fails tb
operate. for -a. period: of el
: two years immediaty following .ahe date of-approval- -of the
_...._,
vert:fcate--of- •-Construction•• Comp3:aeice "'for' "the �se<�age- clisposal'systan, off. 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 system.
The. undersigned further agrees to. accept* as conclusive: the determination of
the Director of the Division of Environmental Health Services-of ithe Putnam County
Department of Health as to whether or not the failure of -to operate was
caused by the willful or negligent act of the occupant o .t e u'lding utilizing
the system.
Dated this /0 nj day of j j %,/ % 19 %. ' Sigpatlire
Title c
General Contractor (Owner) - Signature
Corporation Name (if Corp.) HEKLA CONSTRUCTION INC.'
Excavation *Trucking, Equipment Hauling
• Septic SystRms_ Specialist
Address Top Soil a Fill a Gravel • Black Top
Buckshollgw Rd. RFD 9. Box 474.,,
Mahopac, New York 10541 (. 914) 628 -5738
rev. 9/85
mk
1
j DEPARTMENT OF HEALTH
j
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
.APPLICAT_IOr _TQ CONST-RUCT: A. WATER hE.L•L-
T
PCHD PERMIT #., .
WELL LOCATION
Street Address
Wicco ee Road
Town/Village/City Tax Grid Number
Putnam Valle 1991 -16.7
WELL OWNER
Name
Jim Crocker
Address
244 Center Ave %ho ac
bPrivate
O Public
USE OF WELL
1 - primary
2- secondary.
ffRESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
® BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify;
D
AMOUNT OF USE
YIELD SOUGHTMMS
gpm /# PEOPLE SERVEDI fam /EST. OF DAILY USAGE600 gal,
REASON FOR
DRILLING
MNEW SUPPLY
OREPLACE EXISTING
OPROVIDE ADDITIONAL SUPPLY
SUPPLY ODEEPEN EXISTING WELL
®TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
new residential supply
WELL TYPE
LJDRILLED
DRIVEN
ODUG
OGRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Wiccopee Estates, II
Lot No. 7
WATER WELL CONTRACTOR: Name to be determined
IS PUBLIC.WATER SUPPLY AVAILABLE TO SITE:
Address:
YES X NO
NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY
DISTANCE_ TO PROPERTY FROM NEAREST. WATER - M --AIN: C- renter thiui 1 mile
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION []ON SEPARATE SHEET
4y a1
(date) (sig t e)
PERMIT
TO CONSTRUCT A WATERWELL
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 D artment.
Date of Issue: 19
Date of Expiration: it 19 -Permit Issuing Official
Permit is Non- Transferra le
i
APPENDIX C
....... -]FINAL S TE INSPECTION Date
spected by
TION t Co� �'Q c" OWNER
TM #TOR SUBDIVISION I,OT ,.. .
II.
m
up
SEWAGE DISPOSAL ARFA
a. SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier - LGTH AVG.DPTHk5
c. Natural soil not strit�
- .-
d. Stone, brush, etc., greater than 15' fran SDS area.
e. 100 ft. fran water cQu -r wetlands.
SEWAGE DISPOSAL SYST� ---
a. Septic tank siz - 1,000 1,250
b. Septic tank ins 1 vel
C. 10' minimum from foundation
d. No 90° bends, cleanout within 10 ft. of 450 bend
S
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 required - Length installed
r "f S i:•! -
2. Distance to w-atercodrse measured. ft.
r
3. Installed according to plan
z
4. Distance center to center
/"A 'r l'
5. Slone of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet fran prcperty line - 20 feet - foundations
,
7. Depth of trench < 30 inches fran surface
r .
8. Roan allowed for expansion, 50$
4 wi
9. Size of gravel 3/4 - 11" diameter
Al - •,,c
10. De' th of qravel -in _trench 12'!, minimum
-11. �Pi •ends• �� - -. __. -._ ____..._.._.. _ _ -�- ._.... _ t _ ....._...,. _
..
_�
_
h. PUMP OR DOSE SYSTEMS
1. Size of pump chamber
2. Overflow tank
3. Alarm, visual /audio
1
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 approved plans.
b. Nuamber of bedrooms
a. Well located as per approved plans
b. Distance fran SDS area measured ft.
c. Casing 18" above grade.
d. Surface drainage around well acceptable.
OVERALL WORKMASHIP
a. Boxes properly grouted
I
b. All pi ially backfilled
c. All pipes flush with inside of box
d. Backf ill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall protected & dir.to exist_watercours
g. Footing drains discharge away fran SDS area
h. Surface water protection adequate
i. Erroslon control provided on slopes greater than 15 %.
lj,
_ e
PMAM COUM Y ' MYARn,,DU OF HEALTH
Located at
(T) QA_ yALl -r� Section 1 °1 Block � Lot �G� •�
Subdivision of ,/(GC o ae-
Subdv. Lbt # �% Field Map # c->:2 Date .3 —/.3 -
Gentlemen:'
phis letter is to. authorize Ck7-, �4iAl 1,40-C- -S; 6
a duly licensed Professional Engineer or. Re istered Architect'.' to
�-Zi�ICATE�
apply for a Construction Permit for a separate sewage system, to serve the above toted
property in accordance -with the standards, rules or regulations as promAgated by the
Coamissioner of the Putnam County . Department of Helath, 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 147, Education Law, -.
the~ Public -Health Ia0' - aim` -the Putnam County Sanitary Code.
Countersigned:
PDEj R. A. , # ZC62
E� _
Address 3 0 ,946
Telephone D,� SAM rO�'N y e ep
r' OF jjfaLi .I
Very truly. yours,
SIC,
I
PUTNAM OOUN'I'Y DEPARTmm OF HEALTH -
'00 t.Pf
OF kftMaHFALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
(Name of Owner)
COMMENTS
REVIEW. SHEET - .CONSTRUCTIOh. PENT. ,.
(Street Location)
YES NO I DOCUVIENTS
Permit Application
Corporate Resolution
Plans - Three sets
PO Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
SERVICES
DATE.. - RV "EWID:
BY: _1
f PWS - Letter
ce 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
fig Construction Notes
Design Data
IA 4C Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
avOT Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
_.._.... _._._ _ ....._ _ Expansion_ Aie.,a, s'h own; vity-flma, f.r.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 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 (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
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
PUTNAh1 :..AUNTY DEPARTMENT -OF
HF.A LTH
DIVISION OF ENVIRONIMNT
AL HEAL "AT
•.9ERVIP�'°
COUNl •l7FPick i3mr MING,- 'CAR .L,
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL•SYSTEM
Owner .� /� C OG�G� _ -A ddress
Located at (Street) C.Co�'�'OSl�eO;
?nai�ce nearest cross s ree
Municipality. }?LiL (4 (V-v V qL L C }� Watershed_e
SOIL,PERCOLATION.TEST DATA RE UIRED'TO BE SUBMI7
nu.i cj
Number CLOCK '
ttun
No .•
Start.;-Stop
c�
tuapse
Time
Min.
31 /Sy —1230, y
4I236 - I J
PERCC
Depth to Va7
From .Ground
Start
Inches.
/9
r�fa
60.
.
1 �
r, �i• k�l••tt, a. tgxw
'IONS
ELATION
1'\�`itate
z drop
1
2- e-1 .23r J_. "
20 2 'S v�,� )ter ,.
.• pry � 4�; ).+ �r�;' l yf ' k> �3 •` /�;•'
.i
Vi. Vitt
5
r �
1f.t l
C.S'k +t yJVI� wz
7.
,s,•1;Sp k�t'j`�
011 12AT rt
Notes: 1)
rates are
Te to to be re '
peate`c�U�lt me depth until '8 pproxit►ately,,:equal soil
obtained at eact��coli76test hole,
for. review.
R4 submitted
44cc"" h`
2)
Depth-
measure from top O1� ho1e.
hF,g111�11
TEST PIT DATA REQUIRED TO BE SUBMITTED WITHAPFLICA`tON `.,.
DESCRIPTION OF SOILS ,?NCOUNTMM -. IN 'TEST.�HaLF�
Y 1 - -
ty
�FBFTH HOI:E NO;... TIME N0. ay
G. L. >
' .611
p�
18t1
1 7
4 11 t
k,,
3611
' 1` G t :`'3.�YtxlirLf�t�pS
4811
cat
1
6011
66" ,
2 x
1 TY
i.
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENC
INDICATE LEVEL TO' WHICH WATER. LEVEL RISES AFTER BEII�QCpU
- TESTS MADE BY
•
L{L{KMyy
... --.. .,..0 .. _ ...._.. M . .. N. .. _,i -. ._li ... .._...-w.- .- ..... _ rY b
FWr>
Soil Rate Used/ / -i5 Min/1'IDrop: S. D. Tfsgbl g
No of Bedrodms Septic Tank Capacity ' g,
Absorption Area rov a By— 'L,F.x2411
_ ,3` _ S?.�j• Pte. ��Lt� .........,.._.�..,..._,
• JR11V. 1/ )C_1%'r/
Address -• g 't,�,<
'',� • k
THIS SPACE FOR USE BY HEALTH DEPARTMENZ ONLYs
;2n=
PUITMM. COURrY DEPARTMENT OF HEALTH
DIVISION OF EWIRONMENTAL HEALTH SERVICES
DESIGN DATA - SHEET- SUBSUFACE SEWAGE DISPOSAL
Owner � IM �r- o[, R r Address .7.q ,4 G &.t ^e- 0 r L y e M 010 Pac,
Located . at ( street) �' i ( vp 2 e- Q oci Sec. �Q_ Block _� Lot 16.1
(indica nearest cross street)
Municipality ?tJVX&V& 00ecl Watershed YLId son
SOIL PERCOLATION TEST DATA RDQU= TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking ()pr 3;0 I9gz Date of Percolation Test L-4 I ( q g1
HOLE
NUMBER CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water Fran Water Level
No. Time Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop In Min /In Drop
Inches Inches Inches
19:02-q :14 IL 22-1 2sg 3
2 7:1 S- `i z7 17- 7-2- 2- 3 t
3 q -T,14 � _ 2Z4 I 3 $
v
4 9: AS=
5 (0'0(- 10 :16 15 ii 2 s 3 S-
1 q:07- 't :(9 I z 23 26 3
22 3
3 `:34 /2 22�h
4 J(_ 19 - I(203 1 �": 23 2-6 ,3 S
1
05
L
2 i�/7 r( -.�
.S - : <
3
�v r Pt
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 from top of hole.
rev. 9/85
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 from top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES.
G.L.
1'
2' a n c< <ad en
3' Lo �rdc.e_
4 1 C
5'
6' I
7'
s'
9'
10'
11'
12'
13'
HOLE_ - NO.;.:......
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED IV on.e
INDICATE LEVEL TO WHICH DATER LEVEL RISES AFTER BEING ENCOUNTERED N //A-
DEEP HOLE OBSERVATIONS MADE BY: ��LBIt� -,� CC�coCcci DATE: 5 Maw �i
— DESIGN
Soil Rate Used ►'-1S Min /1" Drop: S.D. Usable Area Provided .gRoo
No. of Bedroans 3 Septic Tank Capacity /O'Z.7j gals. Type Ma sonny
Absorption Area Provided By 37-r>- L.F. x 24" width trench \I
Other � 2 03
Name C o Signature
Address flQ�C.- n
SEAL
h N,, oa
260 Q
ES ASS
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
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