Loading...
HomeMy WebLinkAbout2895DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -2 -19 BOX 24 rL 02895 -7,­7 7 PUTNAM COUNTY DEPARTMENT OF HEATH Rem 3186 N.Y. 10512 Division of Health SeiA s9* Engineer ,Mast provide,.-P P.C;H.D. 6imit 13 kGE VISPOSAL SY STEM . y air V 4 7r VANCE FOR SE, -W "Town, or located �ApLi,-,11 .004?'a -47 Tax Map Block ��' Le" Owner /applicant Name17; 1 00 �'i€t An�) Formerly--- Subdi*lslon Name Subdv. Ut # TJT 13ow 3*1 .9 Address Date Permit Issued Dip` �y Separate Sewerage System built by /101 Con . if sting of Gallon Septic Tank and -3 O Water Supply: —Public Supply From Address or:— Private . Supply Drilled by aa do av 7; Address _AA*V-_Aj0 #V V Building Type ,� utrw en P Erosion Co Com, leted? Number of Bedrooms Has Garbage Grinder Been lInstfl Other Requirements I certify that the system(s) as listed serving the above premises were constructed sep y he ans of the completed work copies of which are attached), and in accordance with the standards, rules and regulat n in _0 t it plan, and the permit issued by the Putnam County Depaxtm nt Of Health. Date artifietl by P.E. R.A. v, Address as Licen ?4 > '�00 .2.4 bOv0 SYStern(s) shall secure the correction of any unsanitary Any son occupying promises served by tt �a )mptly. e.aks such act. par M"I * n as a pubt­_ sanitary sever becomes condlMns resulting from such usage. Approvil,'Of -the separate aware" system shall be available and the approval Of the private water supply shall become -null and old when .8 P4 I y becomes Such approvals are n subject to moditi tion or change when, in the judgrrient of the coftiimr�is' nar' of -such revocation, rnodif lcatlO:Voari&"d"rge IS UC IS ""Itth no essary _WWOW - .7 He" TI le Onto y PUTNAM COUtTfY DEPAMMEM OF HEALTH .r °,'cam 1 C_ rYF: �'f )^, r�p'S`•n�'f4 n '.rr,. ,:��- .�, . L:ifi�.lJ1 :..�- LCD' �;'. .= .�lii�u•��ii-lii�'iF�tsi.rir.^ :��::'C�y:� . Locati - Str t o� LL- Municipality Building Type 4 V 3 12, �> Section Block Lot Subdi.visi.on Name se!5 -7; a 41 fit- �� C Subdivision Lot GUARANI OF SUBSURFACE SEWAGE DISPOSAL SYSTIM 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 -o :rata fur a p:i a two ,years immediately .folla•.r.nr {Y,e date of approval _ of the "Certificate of Construction Compliance for the sewage disposal systc�n, *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 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 �_ of 19 d General n ac or ( ) i.gna ure -) o4-' N46� ,Y y 141,,x,3 - 6- //a 49�_ 6 di! v *__M rev. 9/85 mk Title Corporation Name (if Corp.) Address Yorktown Medical Laboratory, Inc. 321 Kear Street (914) 245 -3203 . Director: Albert H. Padovani M. T. (ASCP) L ABC 7 AIA-In 32.018137; LAB # - - - -- Date Taken: d�- S _ Time V Date Reported: 988 Collected By: 17,7 _ Referred By: Sample Location: S 1eE- 10*4 77 Phone 1! - / Aj I to JC79 Phone 11 Sample Type: J Repeat Test? / (check one) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON-METALS-(mg/L) MICROBIOLOGICAL (CFU /100mL) Acidity Alkalinity _ Chloride Detergents, MBAS Hardness, Total Nitrogen;, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) Copper. -^ Iron Load Manganese Mercury Sodium Zinc MISCELLANEOUS pH (units) _ Color (units) _ Odor (TON) Turbidity (NTU) GENERAL BACTERIA .v Standard Plate Count Z (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE Total Coliform.,_Index Fecal Coliform Index { KEY FOR TERMINOLOGY CFU = Colony Forming Units N/A = Not Applicable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive Le- Potable _ Non - potable _ STP INF _ STP EFF Other: Sample Status: (check each) Outgoing _ HNO3 HC1 H2SO4. _ NaOH ZnOAc Na2S203 Other: Incoming E 4 °C. GT 4 °C _ pH LE 2 _ pH GE 9 pH GE 12 Other: REMARKS /COMMENTS (For Lab Use) FLAP N10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO T YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTI0 . THESE RESULTS INDICATE THAT THE - WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE SATISFACTORY CHEMICAL- QUALITY STANDARDS OF. THE NEW YORK STA E DR KING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. G52�z_ 6e'- Al'hort H VeA nips" 4 ARrPi_ nirPrttnr 2 /86(Rvsd7 /87)RWE . aM c0�r a :.e e � I w O WELL UULv1rijL 11ULV Azruml DEPARTMENT OF HEALTH . _ T)h�i,�:�or.. Of.�, Environmental Health SPj-yicPC PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only s- `} WELL LOCATION STREET AOURESS: WNI. I 1 Y TAX GRID NUMBER: i WELL OWNER NAME: ADORES O PUBLICS USE OF WELL 1 - primary 2 - secondary RESIDENTIALdr ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PU ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT "5 gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE y� gal. REASON FOR DRILLING' R NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH -a ft. STATIC WATER LEVEL 30 / ft. DATE MEASURED � / � �r DRILLING EQUIPMENT 'a ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. 9 OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL, LENGTH fL MATERIALS: RS* TEEL O PLASTIC D OTHER LENGTH.BELOW GRADE ` a' ft. JOINTS: p WELDED 0- THREADED ❑OTHER DIAMETER 13 in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE ZI OTHER WEIGHT PER FOOT Ib. /ft. DRIVE SHOE JaYES O NO LINER: 0 YES ONO SCREEN DETAIL) DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH.TO SCREEN (ft) DEVELOPED? FIRST 0 -YES 0—NO HOURS SECOND GRAVEL PACK ❑ YES NO L VEL ; DIAMETER OF PACK in. 70P DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping METHOD: ❑ PUMPED i tests were done is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER i ❑YES ONO 'WELL LOG ft more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear. 1n9 Melt .Dia- neter PoRTdA110N DESCRIPTION CODE.. ft. it. WELL DEPTH It. DURATION hr. min. ORAWOOWN ft. YIELD gem. 5urtace ,S� r /� J a �o WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ❑ NO ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE ^= MAK MODEL 4` /W�AFACITY DEPTH 6 VOLTAG50A HP 1 '%� /� WE FuIIAME /3'� _ D e! aoo �J "" '�' slGfff= tE r // • �. , 7 (1V6-A FINAL SITE INSPECTION STREET LOCATION S�'�'Gt , OWNER PERMIT # Py " Vr -'71 TM # OR SUBDIVISION LOT # Ii. IV. V. &AM Dateot � 4 Ins by a. SDS area located as per approved plans b. Fill secFi—on- Date of placement 2:1 barrier. LGTH WIDTH AVG.DPTH c. Natural soil not stripped d. Stone, brush, etc., greater than 151 fran SDS area. e. 100 ft. fran water cour tlands. .SEWAGE DISPOSAL SYSTEM a. Septic tank size - q, OW---) 1,250 b. Septic tank installed I I M c. 10, minimum fran foundation d. No 90° bends, cleanout within 10 ft. of 450 bend e. DISTRIBUTION BOX 1. All outlets at same elevation water tested 2. Protected below frost 3. Minim= 2 ft. original soil between box and trenches f. JUNCTION BOX - properly set r 9. TRENCHES 1. Length required - U Length installed 2. Distance to watercourse measured ft. 3. Installed according to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 foot. 6. 10 feet fran property line - 20 feet - foundations 7. Depth of trench < 30 inches from surface 8. Roan allowed for expansion, 50% 9. Size of gravel 3/4 - lf" diameter 10. Depth of gravel in trench 1211 minimum 11., Pipe ends capped h. PUMP OR DOSE SYSTEMS 1. Size of pump chamber - 2. " Overflow 3. Alarm, visual/audio 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 per approved plans, b. Number of bearocms WELL a. Well located as per approved plans b. Distance fran SDS area measured ft. C. Zis�ing 18" above grade. A d. Surface drainage around well acceptable. .OVERALL WOPJQQMIP a. Boxes properly grouted b. All pipes partially backfilled c All pipes flush with inside of box d: Backfill material contains stones < 4" in diameter e. Curtain drain installed according to plan f. Curtain drain outfall protected & dir.to exist.watercourse g. Footinq,drains discharge away fran SDS area h. Surface water zotection adequate i. &-rosion control provided on slopes greater than 15%. 10 RyCr' N 4 7- "F" .. \ a ?''4 -. ^ t af"$r ErsrP'Y A xR*^TME'�N'4'^T v aOsaF ^' uHzrEAL*,sT4H . r `° s 'v"4"'A�4r.`n f 'a` fi;�t .yi "�M1 'h .+ 3 1s'ft ti x b `.fN.'' '4 77 DPIITNAM COMM COIIY n of Envtronmentm Health Services Carmel N Y:1051? Eugln rmlt # r Rev"' 3/86 ` ; Divlsio eee to Provide Pe � s ` ` ti en CERTIFICATE OF COMPLIANCE ���� K 5 CONSTRIICTION'PE FORS A E DISPOSAL SYSTEM '.v Located at ©� Town or village sabdlv181on Name Stlbd Lot # Tax Map Block Lot v/ Benewal_O Revision p s Ownei %Appllcatit •Name • ,, !1 / 7 -- .�i -i �j yy�� Date of.Prevlons Approval Malllng'Addrees /ad �/�ZV�fii G"J' Town Zip I . Band, Type" /� Lot Area FID Sectlon Only Depth - Volmne -- Nnmbtr- of Bedrooms gn Q d . ' PCHD. Notification Is Regalred` en Fill is mpleted 1)`eel Flow G /P /D = �" - � Separate Sewerage system to consist of A — P C1 Gallon Septk Tank aria To be conetiu cted by- Address'' Water'SapPIJ Pabllc Sbpply Frem Address or. Private: zii P : DrUled by = Address 4w Otbei. Regtllrenients I represent that I am wholly antlpcompletely responsalile or. the'des�gn and location of the `proposed systems) 1) —at the separate, sewage ;disposayl-system above described "wJl be constiucteo as showri.on the approved amendment there to and m accordance with `the stantlards rules and regu"a ions o e u nam- County,. Department of Health and that on completwn theieof a Certafieate :ot Construction Compliance' satisfactory to 4ha Commissioner of Healthwill : ha bwltler',that said builder will. be suDmdted. to; the Department and a wrvtten guarantee will be furnished the owner his wccesso►a, heirs or ass�yns by't • y 4 place •in good,,;operstmg condrtaon any part of sand sewago;,d�sposal. system during the.pe►iod, of two (2);,years lmmetliately- follow',ing thedatevofthe issu ance''of the approval of the CortaLcate of Constructwn Compliance ;of the original system or any repair: theretb ;2),that the dolled. well described above wJl be'located �as shown on the appio`ved plan and thatrsa�d well::wall be:In'stalletl din accordan a with:+ he standar s rules and:..,iegu s—li on�of tfie Putnam County Depart 'aril of k4ealth'' � • . PcE R A Date,"!' ate: Ad`d`ress d�' I� License Nom loll APPROVED FOR CONSTRUCTION �iapprovsl expirese year from the date issued un s'eonstruction of the budding hair. undertaken and•�is .� p ., revocable for "cause or ma y be amgnoed or.modaf.ied when considered necessary by the Com issi, r of .H - Any cha}iye or alteration of construct on requires a newpermit: AppioveG for disposal of tlomestac'sanry sew jor pri3 to water wpply .only l ^� Date-'5��! DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Address Town Village City . Tax Grid Number WELL OWNER `Name- ,Mailing Address rivate /7 � ` C i;, f �r. 4fi O Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O BUSINESS a INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION ❑ OTHER (specify O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT �� gpm /# PEOPLE SERVED /0t /EST. OF DAILY USAGE e6G gal REASON FOR DRILLING . NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST OBSERVATION O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE f DRILLED ODRIVEN E]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 / Ar757o -..17 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES i-' NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN /`. ms=s : LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION WON SEPARATE SHEET (date) PERMIT re 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 py 6vii d by the Putnam County Health Depar ent. Date of Issue: �v 19 !� x rj � &t //- &4/uo Date of Expiration: / 19 Kermit Issuing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 287 Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH L1_1-:—.""z-,; —D' I-VI"I"�I-ON Date % . 2-7 Re: Property of Located at ,��� �✓�'� Section Block •� Lot Subdivision of c, J- '401'e Subdv. Lot # Filed Map # � Date Gentlemen: This letter is to authorize 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 connectiori with this matter and to supervise the construction ofysacl �" system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam'County,,Sani- tary Code. Countersign P.E., R 6/ •ess .ye Telephone 0 Very truly yours, Signec Town g%�r 5 y- - Telephone it DIVISION OF EVVIIUMIUAL IMLIN S•ZVICI.S DESIGN DATA S=-SUBSUFACE SELVAGE DISPOSAL SYSTEM FILE NO. Miff- 44. 44 " y-'s-T; Owner- Locat-nd at (Street) Ayze�? r Sec. Block' (indicate nearest cross street) municipality &/77 Watershed SOIL PERCOLATION TEST DATA ROWIRED To BE SuBmiTrm WITH APPLICATIONS Date of Pre-Soaking &7 ,rj- 0 Z or Date of Percolation Test HOLE NU EER CI= TIME PE RCO=ON 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 1,3 -31 2 33 3 4 5 2 ... ... ...... K, 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 P1T DATA RF QUI RII) '10 L11 SU11411'rM W CI51 APPT.ICATION i DESCRM1014 OF SOILS ENOOUNrERM IN '1ST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. 1' 2.r� 3' 4' 5' 6' 7' 8'. 9' 10° 11' . 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS F.hI00UNTERZ D INDICATE LEVEr, TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: O�� 1�,v� DATE:�3� DESIGN Soil Rate Used G'°'S Min /1" Drop: S.D. Usable Area Provided ;rVc) ' No. of Bedrooms Septic Tank Capacity le,d u `gals. Type �.�c�hf y i Absorption Area Provided By . ,3e) e-' L.F. x 24" width trench j Other OF NF tra4°' °sac. *♦ .. Name 1' / jVj AO Signature Address 1 p/ e S SPACE FIR USE BY ONLY: Soil Rate Approved sq.ft/gal. Checked by Date JOSEPH F. SULLIVAN, P.E. YORKT13WN HEIGHTS, N. Y. 105913 (914) 962-4248 ore. D r PETER C. ALEXANDERSON County Executive JOHN SIMMONS. M.D. Deputy Commissioner DEPARTMENT OF HEALTH JOHN KARELL, Jr„ P.E. Director Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 August 28, 1987 Mr. Frank Sullivan 2972 Ferncrest Drivef • ��oSfQ SSaS Yorktown Heights, NY 10598 K Dear Mr. Sullivan: f'/Z' 77P1,/1 .¢q- 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. Two deep test pit holes are required, one in the proposed SSDS area and one in the expansion. 2. Footing and gutter drain discharge not shown. 3. All wells within 200 feet of proposed SSDS and all SSDSt_.'� within 200 feet of proposed well to be shown or a note _.._ . - ._ ... n t _ .:.... static_ n_ •_P exists. 4. To ensure the well is protected, iron pipe is to b located on both sides of the well casing. 5. A money order or certified check in the amount of $100 dollars. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Vezy)truly yours, Robert Morris Environmental Health Technician RM:amm STREET LOCATION PERMIT # I. II. IV. V. MAN APPENDIX C FINAL SITE INSPECTION TM # OR SUBDIVISION LOT # Date Inspected by 10 �t- NO SEWAGE DISPOSAL AREA a. SDS area located 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 15' fran SDS area. e. 100 ft. fran water course /wetlands. SE%kGE DISPOSAL SYSTEM a. Septic tank size - 1,000 1,250 b. Septic tank installed level c. 10' minimum from foundation d. No 90° bends, cleanout within 10 ft. of 45" bend 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 2. Distance to watercourse measured: ft. 3. Installed according to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 " /foot. 6. 10 feet fran 'property line - 20 feet - foundations 7. Depth of trench < 30 inches from surface 8. Room allowed for expansion, 50% 9. Size of gravel 3/4 - 1 " diameter 10. Depth of gravel in trench 12" minimum 11.,Pipe ends capped h. PUMP OR DOSE SYSTEMS 1 . "" -' o.Lr= Of PUTP ��7� }��� bEl � l.iidl 2. Overflow tank 3. Alarm, visual /audio 4. PLznp easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed by Health Department estimated flora per cycle HOUSE a. House located per a roved plans. b. Number of bedroans WELL • 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 WORIQQMIP - a. Boxes prE5ENy grouted 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 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. Errosion control provided on slopes greater than 15 %. 10 Py114N4 UAINI"L NTt,iur4111 r;ii'a&n DIVISION OF EW11 NI71L REAL111 SEVICES -b SIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner %/Y'�:r. Address.GI''�5%`r Located at (Street) All , � , ��"� � Sec. Block � I,ot/2 .. % >� (indicate nearest. cross street) Municipality / Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking / � Date of Percolation Test 21 - ;FT HOLE NLMER CLOCK TIME . PERCOLATION PERCOLATION Run Elapse Depth to Water From mater Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches' Inches Inches 4 5 1 /G_ /S f y 4 M' 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 fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTIQN OF SOILS ENCOUNTERED IN TEST HOLES 4 _ . DEPTH HOLE •. HOLE NO. 0 G.L. 1' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' HOLE NO. i 13' i 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER (BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: / �� yU DATE: _ LJ.:1)lt7l Soil Rate Used © Min /1" Drop: S.D. Usable Area ProvidedCJ</U No. of Bedroams Septic Tank Capacity ,//'0 q gals. Type e�c3vr�r Absorption Area Provided By L.F. x 24" width trench Other Name 5 `v1t%' Signaturae��43 Address xr i j~� THIS SPACE FOR USE BY HFALTH DEPARDTM ONLY: Soil Rate Approved sq.ft/gal. Checked by Date REVIEW S CONSTRUCTION PERMIT - SHEET - - C `(Str e YES N et I J/ C ILE S provided R �- - H 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well I ( ( I VOTER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS 9 �n