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HomeMy WebLinkAbout2992DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17 -3 -31 BOX 25 02992 Flo „ '-m I his No �' Jill ,, , No No IN a Ir , y 6 .� �; f '� , ' mi 02992 f PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES A. YES N Internal Use Only PERMIT -1 ❑ Repair Permit issued in last 5 years of in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION TOWN TM # a e �� " 3'— 31 OWNER'S NAME C_ tee_ Y) C� PHONE # S S`oZ x-72 MAILING ADDRE S � i a riii ew a l l e - 1 0 5 7 APPLICANT QG Me ova Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER CA1,q i'e,,` �, j PHONE ## V(zl ADDRESS Cak- a 4 u � REGISTRATION /LICENSE # / Pro sal pnclude a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE-. The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. n ,, , ,, , n f, � / �, —,-A _ . I, as owner,e9ree to the con ' ' ns stated n this form SIGNATURE �� (/IL-,/, � TITLE 0 A er DATE 6 / U 10 (owner) , tl' - - -sep k% iISWIl6 ,- W i%,* iG coti -IPly with uie 6-6F,dKIoi-,s Of uo3 pef `iit`iur hie sio il%6ystam- i'eNOii" SIGNATURE TITLE DATE pnstaller) .� Pro URMY0 the folloyAng conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of Installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfill until authorization to do so has been obtained from the Department. / INTERNAL USE ONLY Proposal Approved Q� Proposal Denied ❑ '1✓ b /Z In pector's Signature & Title Dat ExplaftloffDate Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 .. !. ¢� ks -r `r a ✓r.:.',:K���?''s y^''ti�S,pY:ryga.• .aq'�r- �".w�+• t v � +s 9,1 u ,1 ;'t r r iS i �i e s ' , t tf r+ o a t 1 v f� v� t f ✓ k '.3` t F +E : t d „fi-t `'',w.,Ai �a„ •Sy M 3"�r r • 5' » S. � xr+x � _ � r PU 'NAM CQUNTY� HEALTH,DUARyyT(1hENT L s r i nt✓ Y c r ayC r .a � DIVISION OF ENVIRONMEOWNW,H AL�TH� ERVtCES � - .y t, a"2, +t h4 1 l -vr''M3. �rtgf w, Y ; x ,r to t ; 9, � 113A -.,11 4Y ra F. ,,.u" + r� httiST' ft� 'fx `., �. ri 3 f q11 Y �((k.s ., J 4 4 „+f pv :rte _ r ... - f ' -. � 4 ri #�"t'''l+�'- �aY`. '3' 5 ' t y.. � .. j �} � lit 1- uY^'�,.,& '" v ro.t vP !, F t' : :i..,.� +K;, .+ w -�•.: r r r'�',»- 1 .� ^F'. xrk # ., y r1 .�l �� Y ar w t^ .ew L' �; x" Ft, x� � PROPS t FdH S`E1N�►G �iut c Ir it i Mme' f k� -� 1. yt ^u" r y t t r ,.:• xN . a 1"+� .. F tw +rt a Fr u^ ;9} a'„ .,} s N. ¢'r� , 4},+zy 4 t + ,�.fy 4. � . r i ;, �"t. u 1 E' d § n3 ., ,rt ,��''nR' Sr 3w 1 trS '�t t t w d.'k _.- y; r F t .+ i"? ti "' ,�r3,i"'�,r ..1ii�.ar:Yy>�' x .,� i;,` s �afr'x'x' #r x`$- "i x .;'i °�iteiril8l'Jse�nl``ti '1�..1�PER� y," �. �v't �Yl r y. ,, ....rw&4c -i Sa,.li u?H..,,..+.... - F't' :. -. �....... .. -.. +. .. _._ .. _ s'. l �.;Yrr'�.tt�d. x. sl.. 1.1 .a�v f F'r4 ; - . 7t 5..: ,,. ,,y-: ,:.. ; .�'.>= ""'x_. s. ^gM1..sitS..Ei s Y:e'^ 3;1crr:at'+r' ¢:._K li "9 can z �r� f ay _ sRepa�t Pem�iE fs�" Jetl in hest 5 y88rs z� s „ Y x O 1i1 $t@rS s " 11 dt fir' +"P {. '`' r..r d a y >~f 4 ?� ,N ti c .n vI' n" "' "w , + ❑ ��'Repairwdhin3Bojrd's��ner�� W BrencharCroton :FeAsRes�a��D818g8t8'" ? s �, ,. 7 �„ y W, >• ', y c` y .s'x .. .. i t i 'u P f 'v s,' 'v .. '"y.'t `*+�'k`1 . , { [] *t4„ ni Repair within 200 fl of a watercourse or DEG rnepped wetland' 0 Jartt RBliew u o. r,�+9 -, '•t F t u�.:.1 9 � "i a. r f �'�.y'S� i i °tom 11 � + �� rr SITE E1,007-ATTIC RI TOWN ; � , Y 'TNI. #' �� �.' •F < ; ,. C tr 1.. 1g. � h 7f ..? 1 t . �. , r>Z". 1. 2}. 4 r 1"""%tis i e 1'.. Y �. `L ! <. i 17'�°:, III, OVNNER'S MEF ¢ r; r -'ENE #a4��#' �t�,: rr, 't7.d�� �� t Y r4'�'�rr.'F`.'�a r '. e +�` 3Sya 4 x{ Y x> ",` y, + ' a f, y MAILING ADBIBE S I . k y fF 4�� =, �� �k ��� ti '� i++ gx. ikT . ; x-£- -' '+' ,� %,,h - y 7 ,R.�,.,, °t t r^y'yr 'c vjv. s yv'y' - g:, -�e-s �'' fr �t'aaY ' w',` r >, ,�+ �^ 3 aSr 5•r 3.. ?4^ �.,, \i wri r'� yes?.. ."4' t'ar• -.,}�; .y s. r �pAPPLICANT£ war sr w2:ir` r r� _ u�'kM���tm �' .. �d ! R� 3- : L .�.. �. 5 i F'= J'9 '.n3x' $"' tlzY-3' N. Wz� i{qr -ia.S T %ti '` i ¢•�� "`}. dl- "'b [ f ',5 °,f �• ,rip p p. �f�f,f� �ww�.>e' tyA'�'+,L` 'Y, `t `4'��dYt' ' '.`>4 },f i' 'S's5�yytr .i +�, 4tF� k I[ J F1 r.3 �i�111V a _� �i V. "f V�„1�,rf WIIO„lf ^• "'w`�r� 5 "fA L'�. Y i A Yf S/L ¢,,di .'!n`�.4F Y3` 5 `". y+ .aa kr 'S tr.,a k r'(n.+ay *eta a <.'� {B.b..gr'^' �� `+5 't"y DATE v f e .... -. TY TYPE 1, r � � 'PC iQ'COMP tII�T # � k t ,J'', frylt �"1.0 'fir ...,yse k � * ,..,rFR.Z _ t .+^'i , r ': ;y . r.'^ . f v T a� '?a51 A n {�tnr �4'.'• 'a s,+li''.t. + • PROPOSEDINSTr' R!'��^ °� PWOi� 3'. " tie z�ka�� rJ.?,-3i yy 3 0 7 ,s a� t,y �r .4 1. y -.0 ``i'r' `' +yi;�' 'E')��4e'ax7' Nx.,�g's5'�...�,s f. t ' l F �c f .� t u,. � '.. t .s s ry y - r ., kfi' nits ;'' 'fiz 4 ter r,i. i" y i, `{,,. - r ADDRESS .� :? ti ga jREGISTRATI(iN /LICENSE¢ #�' �'`�r ilm "112, t r 7, k� .,11i „x i - f 11 ;, ; .,7 .a ` -r-u�. N ' t� j''a?��'!i '�.re� P (in�u e;a seplarateksketch loc�tirig the house, property line 9 ail =a - welis�w11 1fil2 7 . r; t pr,'�"F'Tv.w .,e -rvl? ; -3 f'r' �• '' "`r ,a rt `.^.st Of ff�811d� @�IOC8ltiofl`Of "@X�8tift� 811�i prep08� Sy8t�i1�°�k���� t ^" tat rit est''y ,� F ,� ry g8 ,� ' ti - x -; ..:' .y 1 �i „ k� ` "tiy NOtE The Iertmer�tm�iyr }squire submittal of prop�salfrom i�csed professional dependingonthe ep1 ii s ,��" rµ� �pJ i +.xl :.. �a f� tS`n 1 N .1 I T. nature, and extent of�the repaif F t 1 w y i y��rF 1. x t n. s a '.-ts I < 't j' °4. s !%A.:' ! i 1 r4 ` 3 `f'e.1, b- as r 7 x ittt u,. rr�E {r lF icy" "'°`, f �" t ry4 �1 m,I", Y" '+�i}'Sr r, �'p '. 11 �k. `u' "'t J 7'ro`<y",� ' '- > z ° 3'f P _3 F A r4,. - r> .ice f. % L`� "L.3 .+ tir���tz as i'"L C ¢ -- "'" - t.W4' +>di `sus k "��'Wit ' u:r- 1 % Mi'�y`k 5 xa t s, r n .j-! wy `ktti w r e ,•" /} 3 r sr: ..�. `` `^ i,e'+y.•� * fir.. {Li -r7+-# tx.'. } ..u'rrss: "'!`- zvz}G:..t. .r-v ijy. x?: �r,. ..... ._ - . -_. k"�.`.a. ;_.rr ,.Y __ ��r.�.i..a h"z`a!exJ _ z , Y _:i',a.P.i7"....'.:�"�.���., }., f 't' fY,r a N' _ . w, _x < < .: .1.r' '4;�j'Y`}..rIx,{; '. `z �ytt Fr,-y,,a .'1 r,' t. .r + ` - -: .w : v . fin. { t Y B „s owner;agree to the conditions stated onthis form � r 1. ` 1t.� I 13t .+ d4G. 1 t SIG F TUBE � �, , � �: � � � I �, � TITLE � � � , �t �`� r'�� � � ��A 5 _ DATE �Y F {. 4 - W r'-i f' JS Z. ,>-Ykt 4 r:� - '. I, the septic ii'ltitaller, agree t0 comply NAth th@ conditions Ofthis3p@mlit for thesseptic system re�iir' mss# , ` F _ $, 1. y 9 rG. .. - - !t t� p r r r.... ,,,, +....x -r .-�+ .:r r t x ? °'n e 'max er c . 'r f + -��. 1 > >d i1 s Yt17. ii' ,�dtr F' ' SIG=NATURE TITLE r. ' DATE ':�'. L_ nn tY3 l F n4 1. f �, . 1. 9 Proairement bf TOwiri f if t 4� -&4�/ ', 11 �. Submission_Of as bunt `repair .k6",b­ ythe septic system irisdsUer witlilnf30 days of the nir, ��duplke g. Si. Owners netxl�,aiti Street'Name; Town end Tax W-P number v , F �t 5 , , . . 1. . Loc Uon of lr al�d=com114 _n s fedtto twu ftxed poi t ul P �� 11 e System�desc'iption (e g , 1250 ! Concretie septle'Uhk, etc.) ., t r�`� 1. �> d. Installers' name aril phone numtaer 3 Y s; . `� k t r, m repair t-, be performed `in accordance wild the above proposal and caiditleis s t +� „� z t get # ,., a 1 . v 4 fhetproposetl SSTs repair is Ir>sidered a bust fltdesign and there islno gua[antee a whh the ` v t ay - r w- t y „ ?yF r inn i�lY3, :. fiiplet @dWT$repairlAI��IflJilCtlon �, s, 3`+Y a x t+ y4w � F 3 ti, Y 3 lw completed_ warlc is tq be baekiiiled UW aUffK �tbn to d0., has be@r1 +Obtained irotn the QeparErnent. 1. .... ...�' -_ __ - - rr T..wysx L• 5 �,�....i:�a ?s�'.�,�s ``{y : ilk f _.1 Y. f,_ Y ,. " . MtT ERNA! tE' ONLY:. ,+ `> Pr Quad ;P Denedy ® y Y ¢ f 'LSv7 h�'�4� 7'i : rt T { ' :.. t 4.. r t �lc'�iisv�1'.�r r. < f" � t y � r 9 Y y � 1. .• '�� v r Inspect©r's Signature & Vile Da N ' ,� tr t `, ` �3�.tion Bite t t 1yp _ y j '.i' °;. :t r'tt1 't r ,d rtx" a a . y 'nit' ., ,_W R t . �'+' 7 f .a."3 t'..lk-,. k°*vr 3 r�Z.e.�,r;. l` i. < 'j-,"", ` r � 1 .tr -4 ✓ . k . �% r is; in.Ck��i _Idp1. le COdQS ��.t::...Yes� w. .. t.,r yNo. :;❑ �, j� , z , a,;r,r , C ®PiES'` FCIiD, Ouul+ner;lnstaler f ` �'` a. .. .. •.� .. .. .'� 'mot [ pp\��� - T.4`! [y�., T yr�v q/ -�• ���-F �!1E �'�9�7�:�1wT, .r-& f ,,r'�'1[�t'� L►�a1�C��►T..:. ......,- .:.- :Ti:+= .:::::ri.,n .-s,�... _ -1 .�.'.'9�� Q'Y•:�; oa�= 3i -cir ••�•a�C'1'r.`�C� •'' 4i•• �Ti`r• �T�c' i�. y"' �' ���ii� ':::r�-r"Y•�■•..i- d:':P' ■'o1•v ��J�., .: -:.,.. ... .... .in.e... 34 Columbus Ave Putnam Valley N.Y. 10579 914 -760 6344 Michael Monahan TM 62.17 -3 -31 Date 7/8/10 48 Starview Ave License # 1137 Putnam Valley N.Y. 10579 Septic repair A 1 37.0 B 1 35.0 A2 35.0 B 2 22.0 A 3 43.0 B 3 18.0 A 4 50.0 B 4 20.0 y� s - ��Ui,e- L) � r Sant aY; CENTURY 21 NORTH STAR B45 U28 2822; 4- two IC2 : P? -48,00'N' 113.79 FT 4qlo " -Z2717 F, ;4 /> " 5�=Qvh,-- 4; A,13ktog rp—L :4 cga In wool er . cx ULM^ s"o j L; 7inW -j 113NNODO — --------- 16 5%6 v�� OL, 8tr:8l bO?Z /-:, /T0 20 —7f— 0 b 0, 40.9,7 S T A F. V X VENV ARICA - P.9#4 +/- AGALS 0 44,301 FT. pk%l(3g3 SHOWN NiME91% OFIN4; LOTS 283 260 AS INOW14 ON A CERTAIN MAP W14TITLECI -'WAP "MipLev TV; AMMMUMM".L9. Of CAW LOOKOUT", SAID MAP VA3 FILED IN THE OFFICC Or T9C PUYW&kd COUNTY saicAL-99 Mgptfm" ca nQjq CLINIC OP JANUARY 34, 7 034 AS %dAr NO. (11.• Asti) PA" Of VNIS PARCEL Q(lmQ 0AAr 01 TWE SURVEY Cr PROPERTV swavvs0f elpFOUR IQ, 1$1, 2.32 ACRE PAACCL AS SNOWY OM•A CCATAIAf PREPARED FOR MAP CMTIlLCD ""P Or ► FROPIXTY LOCATED IN . rV *ATt OCl2MA 11,1M TOWN OP PUTMM VALLIM'. 31d) MAP WAI 4 CER71FIED TO :ROWNY .OUQNT TO DATC nLID 14 Int OirrICt Of TNCPVINAW COUNTY GIORGIO VIOLA CLERK Ott WARCM Za, I VAO A$ MAP 329. "k LENORE . VIOLA do XA40 $4~0mw AU 681#11W.09" I-- wo e-zf— I"•. TOWN Or PUTNA" VALLEY sae ROME to 1114. 414110T47r-1111114M I.., c"Alsom, MY 0614 I off—ur. .00— or p-jrmAw (I%j4)A2A-1900 « „Ino.,n.a[4,....... SIAIL OF NEW YORK �yrApar.e Ir A. so.aen as 41[n Me ,r,.,.^ar miluo. ps, L.S. s"o j L; 7inW -j 113NNODO — --------- 16 5%6 v�� OL, 8tr:8l bO?Z /-:, /T0 PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 November 2, 1990 Maria Madica -Snow 109 Grand Street Croton -on- Hudson, NY 10520 Re: Proposed addition Madica- Starview Avenue (T) Putnam Valley Dear Ms. Snow: JOHN KARELL Jr., P.E., M.S. Public Health Director I have received and reviewed the plans for the proposed addition to the above mentioned residence. The plans indicate that a 26' x 20' addition will be added, containing a music room and entry. New stairs and landing will also be added to the second floor. The survey indicates that sufficient area exists to expand or repair the sewage disposal system, should it become necessary in the future. Therefore, based on the information submitted, the above mentioned addition is APPROVED with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by :._.... t.`.is, Drpertasnt. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be replaced or updated with water saving devices, i.e., low flush toilets, restrictors for shower heads and faucets, etc. Approval is granted for sewage disposal only. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Putnam Valley. If you have any questions, please 'contact me at your convenience. Very truly yours, William Hedges Assistant Public Health Engineer MH /jp enc. cc: BI (T) Putnam Valley MARIA MODICA -SN ®W ATTORNEY AT LAW CROTON -ON- HUDSON, N.Y. 10520 (914) 271 -9595 Mr. William Hedges Putnam County Department of Health 110 Old Route 6 Carmel, NY 10512 Re: Modica Starview Avenue Putnam Valley, NY 10566 Dear Mr. Hedges: October 25, 1990 I am applying for a building permit for Mr. and Mrs. Modica for their house in Putnam Valley. Mr. O'Dell stated that,he needs a letter from you, and pursuant to the telephone conversation I had with you on September 28, 1990 I have enclosed the following: 1. a copy of a recent survey showing the location of the well and the septic. The septic tank holds approximately 700 gallons, and we estimate the fields to be approximately 4501; 2 > a copy of the f first f l-oor plan; as' if ` exst`s� and 'as - - proposed; 3. a copy of the second floor plan, as it exists and as proposed; I will call you in a few days to see if anything else is necessary as they hope to break ground before the winter. Thank you in advance for your cooperation and assistance. If there are any questions, please feel free to contact me. Very truly yours, lid, MARIA MODICA -SNOW MMS:ja Enc. cc: Mr. and Mrs. Modica Nt' is Nw k al "m a shop; LA. OVA WAS BETA I YN" P.-N r 44 IV ,t 5 11 kjh4cal�_p.!S+rSZ,r.f �',�'t -s ,ivy n•`'jl+� X' .�� .rX� ��j �?(jfu"�. r .' C a•,1 ! �' � Rai { I L'.�'Y A"'��i Y a+ +. r. ♦thy ,r��� � t � y t : �y ;e�` AA - y a1'li 4 ••�% .S f. 'J}'1" V'1 +•fAa�t ' k Ara 6 1 t r a a T US a •�~ r 1 •ty'4f� r i { OM4 d - �nil IF, N }!; ) Y a i •�Y \ . `��= _ — a !'fir •Y t 1 1�9 � • � V ',f a . I sba:' «s'13w,��'1�2�F;:.:'f�'�� „r.K�. y 4v "I � -, , -� r'� .,.!'.•��C _.. .., :Mt'.:tf ��v�t�i[I�.az +'!; r .� .. ...,. .:. Via:.•....:`... °. _. _..�. ._ e- • .eS"w =1' .rzitrwt9a- oc�YtivMr. o. +...a•. +.a�..wM. �a �w ay. : -.Ya rl.. �'^Mn - �.1.lwN•w ✓. ai*rM �..i�P^•�t w:' .�::�w�+•�:..►� kjh4cal�_p.!S+rSZ,r.f �',�'t -s ,ivy n•`'jl+� X' .�� .rX� ��j �?(jfu"�. r .' C a•,1 ! �' � Rai { I L'.�'Y A"'��i Y a+ +. r. ♦thy ,r��� � t � y t : �y ;e�` AA - y a1'li 4 ••�% .S f. 'J}'1" V'1 +•fAa�t ' k Ara 6 1 t r a a T US a •�~ r 1 •ty'4f� r i { OM4 d - �nil IF, N }!; ) Y a i •�Y \ . `��= _ — a !'fir •Y t 1 1�9 � • � V ',f a . I sba:' «s'13w,��'1�2�F;:.:'f�'�� „r.K�. y 4v "I � -, , -� r'� .,.!'.•��C _.. .., :Mt'.:tf ��v�t�i[I�.az +'!; 7! IY, i I 4 Wit`��•I•_. y , + Y r .°jy 11 r; . '. �! L. ,�.t,•i "r � ` � titt rx' 7Y I t �+ R; •' u�Tti�'t��dy? 7! IY, i I� a�rh +«Ni1.r �Y >.it. fir r O sit anu.. v- �uvt�u �Ya ,��. .. w L. .H f+A•w rs -.:F}� �s+:�+N�� a�w►v'MM•:r Ly ��rK�i.�.� ybv. �. wf•'�tf -'Ww'v- {�.n'M.+GiTi>1v ..•v. �.cwn .v u��.Y,M hw ^�w ww'i �vyl.V �rP • ''� i ^� Cil ti.. ,, �.'i' �:.i ' 7 �... ... �„ `, ..i. ._ � _ (•�. �:.� -'J .... . Z-- .♦ _. _ . .c _ ..� - .�mT -irA �• -vt r ¢ C -c. .. t ^' rr.. -. . ♦ 'J 4 PUTNA_yI COUNTY DEPARTI'IE'NT OF HEALTH DDISION OF ENI VIRO-IN�VIENTAL HEALTH SERVICES DESIGN DATA SHEET —'SUBSURFACE SEWAGE TREATMENT SYSTENT Owner: -1-kOMAIJA i Located. at (street): Municipality: 'P07-NAM 1/84-1-C-4 Date of Pre - soaking: Address: 918 5TAizy /64/ 4yV -' (.Z, 17 - 3 3 TM rt' Section: _ Block- Lot Watershed: fIyD5,cAl SOIL PERCOLATION TEST DATA Witnessed by: _ Date of Percolation Test: Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) SCEs" - t 0-r, . Water level drop in inches �. , Percolation Rate min /inch i.._. �... ..,_. I 2 3 -4 I i 5 2 i 4 5 I I 1 2 i 4 I I I I I 5 1 I 2 i I 4 I t`i o tes: I . T_sts ro be repeated at same depth undl ap pro xi mace iy equal percoIarion rates are .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................... ........... TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES Cc;P7H H (D L E HOLE HOLE;* HOL-c HOL= 4 ^,AJ,L_ 2.0' 2. 5' 3.0' 3.5' 4.0' 0� 4.5' VJ 4 - -- ---------- . ..... 7.0' 7.5' 10.01 Lndicare level at which groundwaier, is encountered 4&A/ Lqdicate level at which mottling is observed 41 Indicate level to which water Level rises aver being encountered Deep hole observations made by: YP. Date 7 Z4, Design Professional Name: Address: S i aziature: