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62. -1 -47
BOX 23
02777
7�
PUTNAM COUNTY DEPARTMENT OF HEALTH
,R,ev.• 3*186 D IvIslon of Environmental Health Services; Carmel, N.Y. 10512,
Engineer Must Provide. y
rz P.C.H.D. Permit #LL
-W!g..10RSEWAV -DISP
YSTEM
_QF,$�OrgEM-ty TION �Comlpy 5E OSAL.
< . 41 Tax I , Ow-n**
/I J J � . .7 i-
Located at 1 0 0 Map Block —Lot
Ownedapplicant Name Former
Zip
Mailing Address
rAl WV
Separate Sewerage System built by
Consisting of Gallon Septic Tank and
Subdivision Name Subdv. Lot #
Date Permit Issued
Water Supply: Public Supply From Address
or:— Private Supply D I r,111edby Address
Building Type
Has E rioi P
sion Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?.
Other Requirements OF Nt
I certify that the system(s) as listed serving the abovi premises were cons c d on the plans of the completed work copies
of which are attached), and in accordance with the standards, rules and r ati a 0 'the filed plan, and the,permit issued by the
Putnam County Department Of Health.
Date or fled byt P.E. R.A.—
Address 40 License No. 2
Any son occupying promises served by the e systems) shall o a sary to secure the correction of any unsanitary
conditions resulting from such usage. Al .sewerage id as soon as a pubt:-. sanitary sower becomes
available and the approval of the private water supply shall becimie null and MY bocofm" avail&bkL Such approvals are
subject to modill tion or change whom, in the judgment of the ;4SgF, I 00mTIsSl r Of S tionj ni4difleation or change Is necessary.
oats Title
--7
4
-DEPARTMENT OF HEALTH
D�SPtlT1�Ai 00� Ol�•'�' HF�.L•TH S�RYrr�
Owner or Purchaser of Building
Building Constructed by
Locati - Strieet
101
Municipality
Building Type
J.L
% A/
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTRA
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 imnediately following the date of approval of the
...�c:;�+.. % }f;n n_ of rc r, r_ r :r,r� �1� i•ar1 P" SFr: _ G C a Piif51 t�
��a� -Cs� - t .i .t-� n m c._ .r z .g- :.xiz -L.?�-
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 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 19 Signature
Title
Gen al tr or (Owner) - Signature
J--I-. L k olu V l)
Corporation Name (if Corp.)
Address ' Aj
rev. 9/85
mk
�§ Xv-,
Corporation Name (if Corp.)
I
irktown Medical Laboratory, Inc.
ij 321 Kear Street Date Taken Ch- =fldp Time: �t Oro
Yorktown Heights, N. Y. 10598 Date Rc' d : - Time:
.......... .
1`2 Tgbj�
Director: Albert H. Padovani M. T. (ASCP)
Collected By: MA- 106Q_4
Referred By: Grp dSS1Ze ftS 6�i �•b�t'sl
T- /�G%2.C�� .E���•i9�3��j� 1 Sample Location: (ju.7SrlbZ -' X�9Wa7-
�� Sf�
32.0 18840 :
LAB # -- - - - - -- . - -
LABORATORY REPORT ON THE QUALITY OF WATER
Phone #
Phone # I Sample Type:
Repeat Test? _ (check one)
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
_ Acidity.
Alkalinity
_! Chloride
Detergents, MBAS
_ Hardness, Total
_ Nitrogen, Ammonia
Nitrogen, Nitrate
—.Phosphate, Total
_ Sulfate
_ Sulfide
Sulfite
GENERAL BACTERIA
'' ✓ Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
Total Coliform
Fecal Coliform
Fecal Streptococcus'
METALS (mg /L)
_ ✓Potable
_ Non- potable
_ STP INF
_ STP EFF
_ Other:
Sample Status:
(check each)
Outgoing
_ HNO3
_ HCl
_ H2SO4
_ NaOH
_ ZnOAc
_ Na2S203
Other:
E
MOST
PROBABLE NUMBER TECHNIQUE
_ Copper
_
_ pH
LE 2
Iron
Total
Coliform Index
_
Lead
_
_ Mercury
Sodium
KEY FOR TERMINOLOGY
_ Zinc
CFU =
Colony Forming Units
N/A =
Not Applicable
MISCELLANEOUS
LT =
Less Than (<)
GT =
Greater Than (>)
pH (units)
TNTC=
Too Numerous To Count
Color (units)
CON =
Conflue.nt ( =TNTC)
_
Odor (TON)
NR =
Non - reactive
_ ✓Potable
_ Non- potable
_ STP INF
_ STP EFF
_ Other:
Sample Status:
(check each)
Outgoing
_ HNO3
_ HCl
_ H2SO4
_ NaOH
_ ZnOAc
_ Na2S203
Other:
E
4 °C
GT
k °C
_
_ pH
LE 2
_ pH
GE 9
pH
GE 12
_ Other:
_ Turbidity (NTU)
REMARKS /COMMENTS (For Lab Use) FLAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THk NV YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TTKE OF COLLECTIO .
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA D KING WATER
CODES,. FOR THE.PARAMETERS TESTED, AT THE TIME OF COLLECTION.
x G� ALP �. 2 /86(Rvsd7 /87)RWE
Albert H. Padovani, M.T. ASCP), Director
FINAL SITE INSPECTION Date
tln
rybd b-V
-ATION
Sn= 10- OWNER
PERMIT # TM # OR SUBDIVISION LOT # Z.
II.
�m
V.
VI.
10
N
-T�77
. a. SDS area locaEi�d as per approved plans
b. Fill section - Date of placement
2:1 barrier- LGTH WIDTH AVG. DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 151 from SDS area.
ea 100 ft.. from water course/wetlands-.")
SEWAGE DISPOSAL SYSTEM
a. Septic tank size - 1,000 0
b. Septic tank installed level
c. 101 minimm from foundation
d. No 900 bends, cleanout within 10 ft. of 450 bend
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
.1
3. Minimum 2 ft. original soil between box and trenches
A
f. , JUNCTION BOX - properly set
9- TRENCHES
1. Len g[Lh required - Length installedVr
2. Distance to watercourse nieasured'. ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 1/32 "/foot.
111,
6. 10 feet from propert line - 20 feet - foundations
7. Depth of trench < 30 inches from surface
8. Rom allowed for expansion, 50%
9. Size of gravel 3/4 --lT" diameter
10. Depth of gravel in trench 12" minimum
11.,Pipe ends capped
h. PUMP OR DOSE SYSTEMS
1. Size of pump. chamber
3. Alarm, visual/audio
4. Puimp 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
b. Distance from SDS area. measured ft.
c. Casing 18" above grade.
c. f
d.- Surface drainage around well acceptable.
OVERALL WOPJ01ASHIP
a. Boxes properly grouted
"s<
b. All pipes partially backfilled
c. All pipes flush with inside of box
d. Backf ill, material contains stones < 4" in diameter
e. Curtain drain installed accordin g to plan
f. Curtain drain outfall protected & dir. to exist.watercourse
—T
9. Yo—ot-In--g drains discharge away from SDS area
h. Surface water protection adeauate
i. Erro ion control-Fro�vided on slopes greater than 15%.
10
WELL COMPLETION REPORT Office Use Only
DEPARTMENT OF HEALTH
Division- Of - Environmental Health Services-
�.s��•x'. ^':. _:a�..�,.• —, -. _• ^-_..:,' a..-^: .�'r- ��a'w�.u.vnr...- ti"�'rr•�.. •'rtr'•.: c.'r-� -... a.•x- .lVr•w _�..NV ^K � •..:�_:.._'..- _..�.•a:.M1..v. �... .._ .• •., w w... •:. .'b's _(.rn
PUTNAM'COUNTY DEPARTMENT OF HEALTH
GRID NUMBER:
ELL LOCATION1 _ I),4,
I/
NAME' v ADDRESS: PRIVATE
WELL OWNER ,�C)3 ,� ❑ PUBLIC
USE OF WELL ;B( RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/CO N .!HEAT PUMP ❑ ABANDO ED
1 - primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE YIELD SOUGHT -�� gpm. /NO. PEOPLE SERVED -3 / EST. OF DAILY USAGE y 62 gal.
REASON FOR ,'NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA I WELL DEPTH' �� ft. STATIC WATER LEVEL -3o f ft. rqATE MEASURED �d !�
DRILLING V3 ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE ❑ SCREENED ❑ OPEN END - CASING. KOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
SCREEN
._._:. -OE AILS ..
TOTAL LENGTH 2! I - ft- MATERIALS: Q STEEL ❑ PLASTIC ❑ OTHER
LENGTH .BELOW GRADE /9 ��ft. JOINTS: ❑WELDED CTHREADED ❑ OTHER
DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE ROTHER
WEIGHT PER FOOT / Ib. /ft. I DRIVE SHOE.J&-YES ❑ NO LINER: ❑ YES 6 NO
DIAMETER (in) SLOT SIZE LENGTH (1t) DEPTH TO SCREEN (ft) DEVELOPED?
FIRST O YES 0 NO
SECOND 'i• ' .. .._._....__.. y. __.. _ . -._.. - .♦ .. ..p . HOURS _..�_��....
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
WELL YIELD TEST
; If detailed pumping
M HOO: 0 PUMPED
t tests were done is in-
COMPRESSED AIR
; formation attached?
O AILED O OTHER
; ❑ YES O NO
WELL DEPTH
I
DURATION
DRAWDOWN
YIELD
it.
hr, min.
ft.
gpm.
i 000-0
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
TOP BOTTO
OF PAECKR in. (DEPTH ft.I OEPTHM It.
WELL LOG
If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM Water µ!eR
SURFACE Bear- Dla- FORMATION DESCRIPTION Cone,
tt, ft. ing meter
In
r
surface / % V iI r�r -PAY .1.r�1n�
I l L).6' I I/,,, I I
._ . rj
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRI NAME
AOOR �fd' �3 '�
�
IGtI)fCTURE
._ . rj
-bii"iiMENTO
PUTNAM COUNT�Y
Rev. DIVI �Ot. "Aronmenfid.R., eim,ces.,&��e 0
sion —7
on CERTIFICATE N PERMIT '0 9ALSYSTEM
CONSTRUCnO PE "0 �d:Dioci
L _491 edl 3'z
SubdIvIds ,7
on Nil, _ S.#bO Toot # L
ewal C1,
/AIV
Owner/Apoll
Date of-PieviousAP'Prov,
A7
_s
be sub 0 'and ,,'il written ,g4.ar.'!�#e��_*!I!,: e,f
in I good th
place opera ing condition any part of
arice of the .appeovalof the Certificate of Construction C6mpi - ii - nc4
will I be located as shown on the, approved plan and ih�`Csijd W, . I "imi- a
Cou nt 0 rtm`nt Health.
Date
y
Signed
171 7 e7
_A
.APPROVED FOR CONSTRUCTION
revocable for cause or may be amen
permit .,'Appro=p
reQuires
e. approval, e�pires,
�his 079* y
or-rri6d'ifie&wtftiin considers
for disposal of domestic sariii
Sy
In
jhs7 y, _ e, ildori that ,said ,builder will
'#tely fo6o4�ing'thedati'6i the iSSu-
t 'jha well ' drilled ` described above
4at
si!quies - and' reg_uraTro_ns� 94 "'the' Putnam
W
P.E.- 'R.A.
X4 License No
of tAFICUilding hat been undertaken and is
oy
n hange or alteration of; construction
V;O
Title
JOSEPH F. SULLIVAN, P.E.
-?-972 FERNCREST.DPIVE
YORKTOWN HEIGHTS, N. Y. 10598
(914) 962-4248
7,
X41- �r� :i
441
DEPARTMENT OF HEALTH
..Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLIC.ATIaN TO CONSTRUCT A, WATER WELL .... ., - . -
PCHD PERMIT #1 t' i
WELL LOCATION
Street Address To Village Cit Tax Grid Number
WELL OWNER
me pAddress r rivate .
/� s+ +' e%/ °� d-l�i - /�� 1I y -,I Public
USE OF WELL
1 - primary
2 - secondary
PIRESIDENTIAL ® PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED
®BUSINESS O FARM O TEST /OBSERVATION ❑ OTHER (specify
® INDUSTRIAL C31NSTITUTIONAL ❑ STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
SUPPLY [)PROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
❑REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
BILLED
DRIVEN ®DUG ®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING?
YES � NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name �l, c' / 037 Address: 4,ael
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
®ON REAR OF THIS APPLICATION 'ON SEPARATE SHEET
r
(date) 79 n
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 De artment.
Date of Issue: ak>- 19 r
Date of Expiration: ~ x /19_ -PTrmit Issuing Official
Permit is Non - Transferrable
M.
•: - APPENDIX B
PUTNAM COUNTY DEPARTmr OF HEALTH - DIVISION OF ENVIRCNMENTAL HEALTH SERVICES
= INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SEIEE,T - CONSTRUCTION PERMIT
(Name of Owner)
COMKERM
required 41 ry LP
60 ft. max.
Parellel to contours
BY:
Pexmit Application
Corporate Resolution
'2 s
Plans - Three sets s/s
Engineers Authorization _
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House P ans - Two sets
Well permit; PW-S letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked _
Ex- approval SSDS Adj. Dots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
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: perc and deep results .
lido-.° iCi.: t.'. �::; �t� .�..r.•.r."'•�''.�"t�r�.�;n7_.L "J.j „!��`�?Gf?Ci . ... .. _ •.
Driveway & Slopes Cut r
Footing /Gutter,Cbrtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
E�cpansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed System
Property rtes & 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,Top of fi'
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expa
15' to Drains - Curtain, Leader, Footing
35'to catch basin,stormdrain,piped watercour.
10'. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to u-nel1
15' Well to PL
6
a
A
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL VVUER SUPPLY SUBSURFACE SEVkGE DISP(
er
(Name of Owner) (Stj t cation)
i INITIAL SITE INSPECTION lJ YES NO
Wetlands on /or proximate to property...............
Property lines or corners found....................
Can estimate house location ...
°°°.°°...°°.°..°..°.
Will driveway need cut......... ee.....:...ea.e...ee
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....... ....... o .... .e.e..
Access to nronosed well location for drilling.....
D.H. '1 Lot-
Depth to G.W.
Depth to rock
Soil DescriDti!
0 ft.
3 ft.
6 ft.
9 Jt.
1L 11.
D.H. 2 Lot
Depth to G.W.
Depth to rock
0
ft.
3
ft.
6
ft.
9
ft.'
House SSDS located per approved plan .............
ten_
" LA
r�
A. U
5011
DATE: ® _
INSP. BY:
D.H. - Deep Hole
G.W.- Groundwater
D.H. 3 _ Lot
Depth to G.W.
Depth to rock
0 ft.
Soil Descri tion
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average.
Slope of tile line and trench acceptable.........
Roan allowed for expansion trenches ..............
Over 100 ft. from watercourse.......... .......e
Natural soil not stripped or SDS area
unnecessarly graded...°...... e .. eeeee..e.
10 ft. maintained from property line and
20 ft. from house.° .......................... eee
Distance well to SSDS (ft.) ....... e._ _ ......e.
Number of bedrooms checks ..............°.°.......
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ....... ...e.eee.
15 ft. of peripheral soil horizontally
fromtrench.................... e e... ....... . e e e e
Boxes properly set ° .......................... ..e.
Could surface runoff from driveway, roads,
ground.surface,.etc., channel near SDS area....
Does lot drainage appear OK,,in area of SDSeo.....:
FINAL GRADNG OF SITE ACCEPTABLE... ....
i°
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property of «%
Located at
(T)
Subdivision of'
Date be l
Section _.3 Block Lot-
Subdv. Lot # Filed Map #�
Gentlemen:
Date
This letter is to authorize7e —; 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 all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
«...._ _.-.. n° r�jr�.` 3:;°[:! •-�- '�-•.�..��'- �'y'C.'.��-2. ^• vri^ c, 3�; f` ^rm.i...Y..,.. \r:_ *i�'F.l�,.,i; o:_ r�iti�: i_ c. f'� V^ +�'n a�,.,' �1f'.�!►7'�::........__.....»:{
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersi
P.E.,
u
Ad ,
>ess
i
Telephone
Very truly yours,
Signed � �'-
'
Owifer of Property
aox
)O&e -S AC• ,GL / a 1-4o ul 120(
Address
A ir
Town
Telephone
DIVfS-ION'0F*.'ENViR0NMERM HEALTHSERVICES
DESIGN DATA SHEET- SUBSUFACE 'SEWAGE DISPOSAL SYSTEM FILE IAA.
_.. ._Owner K. �Z- ✓a,���/ �'" �� Address
Located at (Street) /�i f Sec. 3 ' Block f Lot
UnAcatg nearest cross street)
Municipality U A-747, L'L" Watershed
Date of Pre - Soaking
Date of Percolation Test
HOLE -
NUMBER -CLOCK 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
4
5..
5
1
`a
3
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 suhmi.tt!l
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
TEST PIT DATA REQUIRED Ta BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLFS
DEPTH HOLE N0• ■[ I HOLE NO. HOLE NO.
r . r c...a ..- ..� -: �...- ..+ ...i:.r � Ir- v.. .. -.. .fY^a Yr_ ��� a ���•' i is _ __w -k � ..F' ..-.. '� 1 �. ',•I.�.a. ^: v T_'•...�-�It ^.'.�'i':.'_�'T
1° s
2'
3'
4'
5'
6'
7'
14°
..__._ _ -; -•- Iiv19IC: t�ir,�i;Ev�'ii-''v`ticlui-'v�-c vii v' - i` o-.` �vv3'�i'ti�T-'•",.,c-.�3:�._...: a�, ��7-���..�i'='� .__.._ .�::. _._.. � �_.
INDICATE LEVEL TO WHICH WATER LEVEL RISES _ AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE
DESIGN
Soil Rate Used_ Min /1" Drop: S.D. Usable Area Provided }tea,°'
No • of Bedroams Septic Tank Capacity /i��' gals. iii v" y
Absorption Area.Provided By L.F. x 24" width trench
1
Name Q f���% Signature ...il
2 H
Address?
IZY14 !!-z
THIS PACE FOR USE BY HEALN DEP ONLY:
Soil Rate Approved sgoft /gal. Checked by Date