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HomeMy WebLinkAbout2672DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -1 -23 BOX 23 02672 16 r m I - or 02672 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N Y 1051 r CE CATS OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM_ T -or Val 4. n� Located at C6,- V%e Ti::Msp Block Lot y e Gera s � t �t Formed Subdivlslon Name Subdv. Lot # 1. 1 Owner /appllcaat Name —I... Y tt ' Malting Address. Nli11,vsac�T_Zlp u5 7 Date Permit Issned 7I Separate Sewerage Syetetn;bailt`by Address / Coneleting'ot Will Gallon Septic Tank'and Water Sapply: PdbHc Sgpply From Address :or: PrlvateSapply`Ddlled.by r W�� 1�' �Address`n�� lua�•�( - /2Srf0 Buudhtg Type t'Co 14, Has Erosion. Control -Been Completed? &A Namber of Bedrooms Has Garbage Grinder Been Installed? .t7. Other Requirements I certify that the system(s), as listed serving. the above premises were cons dted-essent lly as-shown on the plans of,the•completed work f copies of which are attached), and'in accordance-witti the standards,: rules ind're a cordanc win the filed plan, and the permit issued by the Putnam County Department Of Health. Date lilt I i ,.. Certifi d by .. A. P P.E. R Address 24 2 ° ". k License No. 3�3 Any person. occupying piemises se►ved by the above systems) shalt promptly take such action as maybe necesfaiy to secure the correction of any unsanitary eondltions resulting from, weh usage. - Approval of the separatewsewera9e system shall become null and void as soon as a DubR_.senitary aavwr becomes available bnd the:,sporovil, of the private wateriupply shall'become null a vokf when a public wate supply become walgbN., Such approvals ere subject to modlh tlon or change when; .in the,ju_ Ment••o1 .:the 'com over of N Ith, ch revoeatlon, modification o► chanpo is necessary. ZileOats BY Title 43— PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMMAL HEALTH SERVICES -. ' ?� -_ �. .. x -� - _ -i_�:- <r .� i• _ � .r � •. ..� n, s.:_. .'9. r�._-. �+ ....�. _ ., t...y ..f..t •+:f� sr.. -'.E'- i � a .. �[•.z ... .. � -.. Q 2.1 owner or Puiecha ser of Building Section Block Lot Building Con tructed by Location - Street P k-1, v JL-ar Municipality (Ze s : e.A- c e Building Type 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 imTedi.ately following the date of approval of the "Certifica.te of: Construction Compliance" for the sewage disposal system, or any repairs made by -ine" to '" ch " systdrn, '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 Environinental 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 J tion Name (i day of _ 19167 Signature Title - gnature Corp.) L&r)to t l :a I� s L U V Address POT OIL �IAX14AI ' rev. 9/85 mk CQV Name (if Corp. /) Address Yorktown Medical Laboratory, Ina LAB ' 320 009169 321 Kear Street _ Yorktown fIei hu N.Y .10 9S _ - -_ - Taken: - _ _ _ .. 8._0 �...r Date Ta m . .5 °d Tim a (914)245.3203 Date Reported: Director: Albert H.PadovariM.7°.(ASCP) Collected By: -� Referred By: Sample Locations ° bi,( C'a'd -C"� mil 13 y - u .v , _ . Phone � 1)71)-L (�Jp� BUJ �l� Phone Sample Type: °j Repeat Test? one) LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY. OF WATER GENERAL BACTERIA Standard Plate (Agar Plate MEMBRANE FILTRATION Z Total Coliform Count (CFU /1.OmL) 35 °C) TECHNIQUE ('MFT) (CFU /100mL) Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /100mL) MOST PROBABLE NUMBER TECHNIQUE (MPN) Total Coliform: MPN Index (per 100mL) _ Fecal C'oliforin: 'MPN Index (per 100mL) Y OTHER ANALYSES REMARKS (For Laboratory Use)' Potable Non- potable STP INF __. STP EFF Other: Sample Status: (check each) Otrtgoing Na2S203 .Incoming 1/LE 4 °C GT 4 °C KEY FOR TERMINOLOGY RDS = Recommend Disinfec- tion 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) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT_Tn TIME OF COLLECTION. /xl / :: a_4</® / �c Albert H. Padovani9 M.T. ASCP)9 D For Lab Use Only: H/C to rector I.. W. V. 41. i . mTo APPENDIX C FIML SITE INSPECTION Date ° � S GwN� Inspec' by � ^ U�. I - _-. _ .3:i..'a OEt ':.'��t�IV?SIE�1:= i11���:c�= --- >7- ;•�.%. -.._ .. _ ». _. - �S- DISPOSAL ARF-k Led as per aonrave3 plans a_ SDS are; Icca- b. Fill sectica - Date ct placerfeent 2:1 ba -Trier _ LGTii W"rV= 'I'fi ANG _ D= I c. I�at7ar l soil nct s -- icce -d I d- ' Stone, brush, etc-, greater t-L-n 15' fran SDS are---- I/ I e- 100 ft. f_cn wat.Y tour_ wetl ark�4-s. I I SErO.G✓ DISPCS ?L SYST --7 c 2 .:;t? c tWnk size - _, 000 1,250 b_ Semitic tank it =�? 1= I I i C. 10' mixiirn= fran fcuncati cn d. No go' bards. Cle7--r.cut w? thi 10 ft. of 450 bZrA e. DIS'L- �'LZIGN BOX 1. All cutlets at same el ev-aticn - Wite - tee t -i4 e-:!�7 2. Prote `e? be? caw frost ( 3. M-Linkman 2 f t_ cricin _l soil t_ x and-t= �-�c:-!es I I _ ✓� EC f . JL'I�CTICN X = prcc rl v Se I ( I g- TEON - 1. L? ^_c``R r ;= - [,,Jo, A LGnc�L-1 ins to 1- _ 2. Dist -nce to wat =rccr— c mews -a e •, 3. L-is t=- l l =A actor c- r.:c to pl an I a Distance cent to ce_riter 5. Sicce of trench acc=ent: ble 1/16 - 1/32 6. 10 felt fr.on vrct��y line - 20 f fcmr ticns ( , 7. Deoth cf tancz < 30 inches frcn s•`r_ace I I 8. Patna allcwed for ��.�n =_ion, 50% 9. Size of ravel 3/4 - 1j" 4.iZuet° 10. Deot_h of c -avel in trench 12" mi Lama I I 1 a .: ._31. 'Pire.Encs = -4e- PUT OR r, -SYSTD','S ...:_' ... ......................... h. 1. Size of p= chan-b T _ _...,.. _... II 2. Ctie.*-fl7.q t=ank I I 3- Alarm, vis- gal /aL'_cio I I I 4 F.mo easily acc= —sible ir`r-hole to grade 5. First box baf_l I I 6. Cwcle witnes=sed by Ee=1tn Dec* tre.nt esthrated flc,; par cvcle I I I EGUSE a_ Ecu<z locrte3 remr accrcve3 laps. b. NL-.,a:er cf be%roan5 I firer. sL a. DveL_ lcc._tea as rx--- . ar-oro ed vlans b. Dist=ance frc n SUS a*-=—= ft. c. Czsin 18" ahcve- grade- I i d. Surface drai race arcund we-11 accent_ble. I GVEZAIL WOMMASHIP a. Foxes roce-rly crcuted I b. Ali pines *-`,-ia11v backf:illed. I c. All pives flush with inside of bcx d. Fackfill material ccnt_=_ins stones < a" in diainater e. Ca-thin drain inst 1ed according to plan f. Cartain drain cut.fal1 protect= & dir.to eY ;C.L. ; te-r=uxr -s2 c. Fcctinc dre i r= d; - sc arc` away f_an S"DS are L h. Surface wat- -- prct r-`icn adem --- t_ I i_ F— csion control rrcvlded on slcces cry tee*' ttan 15�. �I e, !e o. . _. _.._ _� .. ......_.... �....� � � �.. .....:_ _,�_ _ .::._ ...,�. .... �..__. __ _ _. _....._.. _ ._... M_...._ ..._ _. � _._ . �. , . 71T_�91T,_,;=11 .7v m t�zm, 77 57 V; V, 4' PUTNAM COUNTY,-,6]kP,"�kTM"Nt-O]VHEA'UTH ie'P. 3186 Dhdidom-bf Environmetltal Heilth`SiMcii.lbrmeI N.Y 10512 Engineer tw P146VI ie Permit qL CERTIFICATE OF COMPLIANCE; CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL'SYSTEM, Located at L.&6- &u 77 Town or _VWege 7 SubdNbfon Name —subd. Lot il -L4)t — UeWai� 0 Revision. D -A al Date 4preil, PUS. PP 'MalMn -DID O!M g Ad&ess Town— P.- C. ra – Y Bioding ype: Lot Ae Dcdob Oid*_ L Do th Volt P Nmnbe r of Bedrooa; Dimgn Flow:G/P/D PCHD Notficaton b Required When Fill Is completed, Separate Sewerage System to Couilai of Gabon: Spoqc Tan#, arid To be, ConjtMCWL by if Addirm Water Suppip � or, k��Pdviti�Sa�jl�, Drilled Y, Ued Lddrgss Tj� IV P Other ReIqWre*' ji iti _- repT ra—�t M Who y responsible . or �the design and ,location ' cilf th,e`.�,proposed system(s); 1) that the separate sewaia,disposm system w standards, rules andre constructed - sho ithiha'ila above described will:Pe'Lc, gulptlqnsoj the..Putnam .County bipari�naht��.- -�thp� cip co.T61,�tipri t,hereo &.1.1carti icai t j6ce!'� saii'llactory'to the .Comffiissioner, of.:Healthwill 1�4�!t h;", 4 h,� n be ' subriiitttdL't��tp-��.'06�iiji�,80�::��d' a ,written guarantee �tili, be furnished a he owner,��hliiuciessors.' heirs qr,assjiq�s,by. the builder .. that said 66ilder will. 61, 1 �­­ ­ ; a'L, r, �,­ _- , , I I . 11, d . ace in -gocid`,66eiitinj -of,ii;ci`iiwage disposal �systern h­""" e,perood, o two (2 fo(lowing* the dafe�'of the' is! )years imme lately, .�U7 the r� 'j� a j­1­ jj&­,t hjrajo;"2) that 'ante. approval' Construction Compliance of _4.- ),­­ 4n the drilledwell described, above d 'rules 1 will b anti that .9 iqcatec��!s tq?,approv pjan Said well Oe�i unty. Dip' t r thal 0 st r S, ,and regiuMoriF of the Putnam pprn.on iC qt ealth.w -Signed Data Fi.k. R: A A -- --------- --- ------- Address ' — + License NoIy A'PPROV,tD.F0R':CONSTRUC.TI,ON'.. This approval -expirii'6 om7" at oed'�.. 614'ss cRvli�mu.Oorlon �o the building 'has 6ean'undertakah and is r .0 d It mis fi eath fA n n o cons ruc revocable for cause .may be mended change or • i f are t9,,atio t tion diS`p'os'ai'of, d0im'esflc iiqlt' s a and/ r only '�e 'a o l9d,when considered u i -ne Date :By it a Division Of Environmental Hoalth Services t IWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641 - - -.. APPLICATION TO CONSTRUCT A WATER WELL Y,� .,-� n -_,`� 2. •___, -•c!.l _LOCATION STREH . Ca_wo — - TOWNj VILLAGE) QIV IJAx Q%0 NuMR& xA k uS LL OWNER NAME. • �eoc e AOOaESS: ��z� �`�.�►��,�� �:i_ p- �IVATE 0EUBLIC OF WELL " 8-RESIDENTIAL ❑• PUBLIC SUPPLY' O AIRICOND. /HEAT PUMP ❑ ABANDUNED primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) secondary p INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ UNT OF USE YIELD SOUGHT S gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGE L 3 v o gal. ASON FOR CEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION TRILLING- ❑ fiEPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL ELL TYPE I Ca-DRILLED E] DRIVEN F] DUG GRAVEL ® OTHER WELL SITE SUBJECT TO FLOODING? YES ENO WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: -AJa i LOT NO.: TER WELL. CONTRACTOR : Name 'a o ire dW6vmkJ Address*: PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES —W-6, - BE OF PUBLIC-WATER SUPPLY: - TOWN /V /C :STANCE TO PROPERTY FROM NEAREST WATER. -MAIN _ ICATIOIv' .'SKETCH ° & SOURCES OF CONTAMINATION, - - - . -See • n� , .. � :...... (date ) ' 1 ( signature) - -- - - _ PEWiT'' 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 thew .York State Sanitary Code, and provided that.within thirty..(30) days of the completion of water well construction, the applicant shall: to Pump the well until the water is clear. 20 Disinfect the.iwell in accordance with.the. requirements of the Putnam County Health Department attached to'this permit. 3. Submit a Well Completion Report on a fonw provided by the Putnam /County Health Departmen > Date of Issue: / /7 19 % - ,` 1,?1141 , � .1 - L raga "t Issuing Official Permit is Non - Transferrable Inches Inches Inches l 30 23 2 Z S •` 2 _3­2 13 0 Z3 �.: 2 ,�► 2.2 S V3 3.3 -A' 'Z3 5 3 5 NCri'ES: =:;tip. •Testes tc 1ae repeated at same, Aepth until approximately. equal soil rates obtiai .at each 'percolation test. bole: me. ROLE HOLE NO. DE:pM HOLE ND. G. L. --------------- 20 L 9± 30 0 L � A 13.0 140 INDICATE LEVEL AT Ua87c��!" GRC�tJ[�1i�fT�t "� °:�� �?° "� INDICATE LEVEL To WHIG WATER LEVEL RISES AFTER, BEING ENOOUNTERED DATE: DEEP : BOLE OBSERVATIONS MADE BY -900TT L Soil Rate Used S.D.. 16sable Area PrOvidec --------- gals ype c y Se ptic -Tank Capacity --No. of--Bedr(=G ..Absoiption Area. provided . .By _,.. ___ .t Signature Address SEAL SPACE TOR USE bx Son Rate . Approves . - I -� -i PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMERM HEALTH SERVICES INDIVIDUAL MUM SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS FIELD INSPECT ON REPORT _ :-�-X. -tKiV : ._ n. �., - ... - _.. 'DATE: INSP. BY: (Name of Owner) (Street Location) INITIAL SITE INSPECTION YES NO CCMMENTS Wetlands on /or proximate to property .............. Property lines or corners found ................... Can estimate house location .................... Will driveway need cut....... 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 ............................ D.H. - Deep Hole G.W.- Groundwater D.H. 1 Lot D•. H. 2 Lot D.H. 3 Lot Depth to G:W. Depth to G.W. Depth to G. W. Depth to rock Depth to rock Depth to rock 0 ft. 3 ft. 6 ft. 9 eft. �. t. r, - .,..... _:_ .:12_ft�. �_:. .._ ....._.� . » - 12; DATE: FINAL SITE INSPECTION' INSP.BY: YES NO CAS Soil Descri tion Soil Description Soil Description Length of trench measured 0 ft. Width of trench average 0 ft,. ,• Slope of tile line and trench acceptable......... Roam allowed for expansion trenches............ •. Over 100 ft. fran watercourse .................... 3 ft.' Natural soil not stripped or SDS area 3 ft., unnecessarly.graded............................ 6 ft. 10 ft. maintained from property line and 6` ft 20 ft. fran house............................... Distance well to SSDS (ft.) ...................... ,.: 9 ft: Stones, brush, stumps, rubble,.etc., greater 9-ft. �. t. r, - .,..... _:_ .:12_ft�. �_:. .._ ....._.� . » - 12; DATE: FINAL SITE INSPECTION' INSP.BY: YES NO CAS House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Roam allowed for expansion trenches............ Over 100 ft. fran watercourse .................... Natural soil not stripped or SDS area unnecessarly.graded............................ 10 ft. maintained from property line and 20 ft. fran house............................... Distance well to SSDS (ft.) ...................... Number-of bedrooms checks.... .................. Stones, brush, stumps, rubble,.etc., greater than 15 ft. fran nearest trench........ 15 ft. of peripheral soil horizontally fran trench :. . Boxes properly set ............................... .. Could surface runoff fran driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage. appear OK-11i area of SDS::......:;. FINAL GRADNG OF SITE ACCEPTABLE::".:. .............. s �.. f PUTNAM COUNTY.DEPARTMENT OF HEALTH DIVISION -OF ENVIRONMENTAL- HEALTH SERVICES Date°��� Re: Property of �0�6 E LLN 'D�`C` Located at C- pt3oFuS rl LL D (T) ?i.�v.aw. yJVM'N section ,7 Block, Lot 2,1 Subdivision of Subdvo Lot # Filed Map # Date Gentlemen: This letter is to authorize "A - ZE QZ a duly licensed professional engineer or registered. architect (Indicate to apply for a Construction Permit for a separate sewage .system, top. -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 _...._.. . - -system-9or- -sys-t- ems.- i- i-= c-on-formity--with the prcwi� ions - -of•- Article• .145; or - 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very { 9 Signec Countersigned: P.E. , R.A. , # Address 2G s —'fo lid Telephone Address Town. 91.4 6). NS1 , Telephone pUTNAM COUNTY DEPARTMM OF HEALTH - DIVISION OF ENVIROINIENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS 1 '1 F IELD INSP E ON REPOR T , (Name of Owner) ( Street I(ocation) ) INITIAL SITE INSPECTION YES NO CCMMENTS t Wetlands on/or proximate to property .............. Property lines or corners found ................... Can estimate house location ....................... Willdriveway need cut ............................ 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 ............................ D.H. 1 Lot Depth to G. W. Depth to rock Soil Descrivti< 0 ft. 6 ft. _ . r 9 ft....F�,` --- - ------------ Deep D.H. - Hole - G.W.- Groundwater D.H. 2 Lot D.H. 3 Lot Depth to G. W. Depth to G. W. Depth to rock Depth to rock soil Descrimia 0 ft. V 3 ft. 9 ft. 12 ft.l 12 ft. DATE: _ FINAL SITE INSPECTION INSP.BY: House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of the line and trench acceptable......... Rosen allowed for expansion trenches .............. Over 100 ft. fran watercourse .................... Natural soil not stripped or SDS area unnecessarly graded............ ..... ........ 10 ft. maintained from property line and 20 ft. from house... ........................ Distance well to SSDS (ft.) ...................... :Number of bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench ................ 15 ft. of peripheral soil horizontally fromtrench ..... ............................... Boxes properly set ............................... Could surface runoff fran driveway, roads, ground surface, etc., channel near SDS area... . `oes lot drainage appear OK in area of SDS....... 'VAL GONG OF SITE ACCEPTABLE.. ... Soil Descri 0 ft. RQ(( VJ•" 3 ft. 1 6 ft. 9 ft. 12 ft. GAS -i SHEET - CONSTRUCTION PERMIT. Na a of Own r.. Rv. ` I.' /. DATE Tax Map # Street Locate on • - -• ,� CC S YESJ NO D05MTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization - Design Data Sheet (DDS): Deep Hole Log Consistent Perc Results (3) f 30" Perc Hole Other ee` House Plans - Two sets If PWS - Letter Variance Request RDQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume _ D or J Box Detail Septic Tank - Size, Detail Well' Detail, Service Line if P.gS Trench /Gallery Pub Pit Two -Foot Contours Existing & Proposed Slopes for Driveway.Cuts. Footing/Gutter Curtain. Drains.';;:': Perc & Deep. Holes. Located —,-Representative of Sewage,& Expansion Area Expansion Area;' shown; gravity. flaw... If Pumped Pit -& D Box Shown & Detailed House No. of . Bec rooms: ". Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds _...- "� ::.. :..:.-....._ ....... _ .._..,._ _.-_.. -House `Setliack Necessary ._... -- . ...._ House Sewer - 1 /4 " /ft. 4110; 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,Stom,Leader,Footing 25' to Catch Basin d 10' to Water Line (pits -201) Septic Tanks c---' 10' fran Foundation 50' to Well - z. -'' 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked -, .'" 16n)' f' L.__' r Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same `� Well Permit ii 0 • DF; A .n a m S2 K5 wh" ZT I D Z, 0 VA Ps. I Y.1 ri h: It . 1. U L 0 T__21 ­ 2.. 3- ZI)D 3 -77 4 5 2 3 ­4 ibim T iit tp� 4be repeated at same depth until ?rcxmtely equal soil rates j)ercb1�L4on*. test,, All- data to'be submittl3d at'each bole... vx e v - nts to 'be maAe 'frcia top of hole. rev. 9/85 DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTER PUB NO. Address... 6-6f -f s 4� 1 �A. wcv Located at (Street) Sec. 51 Block 14 Lot 2.1 ( indicate nearest cross street) Municipa1ity Watershed AIJI SOIL PERCOLATION TEST DATA PJ)DUIRED 70 BE SUBMrr= V= Date of Pre-Soaking ��u Date of Peroolation Test tA!h ROLF, NUMBER Cr= TIME PERCO=ON % PERCOLATION Run Elapse Depth to Water Rrom Water Level NO. Time Ground Siirface. In Inches Soil Rate Start-Stop Min. Start: Stop Drop In Min/In Drop Inches Inches Inches 22_-Z 2 23-1 -3 00.) 4- 2y_ 0 T__21 ­ 2.. 3- ZI)D 3 -77 4 5 2 3 ­4 ibim T iit tp� 4be repeated at same depth until ?rcxmtely equal soil rates j)ercb1�L4on*. test,, All- data to'be submittl3d at'each bole... vx e v - nts to 'be maAe 'frcia top of hole. rev. 9/85 OF 3° 49 59 6° C7 7° 9 -1a Q - LU r_,._ 4 129 Uj z. IQ _ a® LU 13° 14° - INDICATE I8M'AT'_WHICH­-MUN9AMM IS..R=-UNTEM w�� - --- I &I M LEVEL TO WMCH WATER I.EM RISES MER BEING ENOOUNTERM DEEP BOLE OBSERVATIONS MADE M. DATE: . DESIGN . �rp 2 Soil Rate Used -to S.Do . Usable Area Provided_. �9s- t�,/1. - ..Drop: .- - -... _ - b. a..Bedrows -..: tic Wank ca, ta��.. .-- ....__�...� � `�'..... . balsa _ .Type . - fibs tion Area Provided. Other .... .... ..:.. '� ...� �. :. -. _ • mow... � ___.._... �. ,._ ._..a..,: • ._._._...�,,.,;•�:•• ..::. V:+:;:.'.,:.....,.:._:___.._.._ �, . -T Nam& Signature Address MZ_ SEAL� AJe --n z, . . . .. .. ...cu�..l.. ��k :..,a..ta•� �i.l�:,:✓�e.� &tu:� _ .:.. - ..�•1:'''"• -i � r.�y:' .t+ ... 7HIS SPACE -FUR USE PRO Soil Rate Approved ° °? ° g+; .o�gl o"�` dat: �, `u:aW;: �. » ;: t uJ 1 I. c sa G1.oll it 3 5$ for �j3J.11' �2 E 4 y 2 i 5 to 5 9 F . I 6 A ,),I 3 bdrm I' feSldElIC9 i (h Z i S1 ° I SZ f3. N 40 ' tis ;T 01 tb c 1,13 r; �P y�. F N �5P N 21.51" Sb E > F. 31 " Y1 IF , 5-11 All 'a5 Ai P'S I 3 5 6 7 8 1 9 1 10 4 21 SI S I 41. 41 '7Z $5 bri ,g To —ZZ 66 61 5Z I