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Home My WebLink About3118DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 63. -4 -6 BOX 25 NoIll 09 rm loll 1 0 PN No �, ir , L � � �� ; � '�� No 03118 7 `,__ DEPARTMENT bF. -HEALTH' iloWdh4or, 611' M JJR 0612;—, A E CONSTRUCTION -C614,L, IAN, CIt FOR 'IEWAGE'VISPO LlYS"Ti �O 0. . Loi Tot; # Subd 4 �Sopaiate s6weifi 'fit 'b 0 .6d of &l. Tank -arid 7� -7 Other X Water' Supply From ' 'A Private, -Supply -Dimo� Y. Ad No. of Bodr66rris '-FW od- Building .1 ype Date mlt 'Issu ni 1��dj "Hm, ,�,Bopq o.n:..Contrc 0 .,7 a115 'bhow� 6, the 'piani 6 e.cc ;essenti i.os, em were . .1constructed , 'bpi_eidci 1woik i.c ify- thitt Ithe -.sYst '(i,)" �#s Asl��d dl.i�ing the�,�I�v i I ch aie,aia6i�oaj:i"", n rules 1 on,p ',wit 14�e, ffl�d pia�'; a' e,'j4rmit issued q and i _aqcp;danqe,wIih i:6 'sfaiidi d INI " `a,nd. a acc8'idin�o. �i, and th AIL 'Putnam County 4 baio� �:Px..�� A.A. Iiii N A dress, .7 u nkiry' jny, por�on..q ying, abi�vq. i6ill, prompt y take 'suc*ti ikii6n "a'*�,T'a;y�'"_.g!,F�sury,to'ncure 'A lon, ,oi any :.condition; I hj -fro r�i6ch usmjt."-- Approval 'of thdlji t :a t eml-T!" ol;�� ! ! . ri!,ary�,�Wvvw scon Cart fW by ply-shall,becom n nu .;b?com": available a,n&,t,",L�ap0rqv the private water Su eh I re, _ypto �wat�(,kyp.. a--`publk:,.w8t s if jhii - mod 11101s�n"V;*: ls'necomry. WOO� PPK subject ;o' p f I 'ingo'. -,When, In 't 66 -Judgimn6nt�,, paf4 hh's, ion f -Ham Ification or: ch odi, ication or thO L 4, M ,77 Q DATE OF REPORT W DRILLE gnatuyA)_ DATE COMP 1E RECEiVED. (MAR 2 5 105 PUTNAM r I f ' . . DE'P.�'. OF "Ouivey 1 HEALTH _ _ WELL 1 _ : MPLE710N �TfPORT PUTNAM COUNTY DEPARTMENT OF' HEALTH 3171 �!" �, r ,c Division of Environmental Health Services COUNTY OFFICE - BUILDING - CARMEL, NEW YORK report, iS to be completed, by well driller and submitted to County Health - Department :together with laboratory report of j ysl of water samz�le- indicating water is of satisfactgrYst�a��r�ajquallty_ befgLre cenifica>ig off nstructligr compliance is issued -�_, _ is REPORT. MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION . E ADDRESS OW At - lOC .: of (No. '& Street) "(Town) _ (Lot Number) 1 �CQ3 6 /% G ((y�am BUSINESS 9DOMESTIC ❑ ❑ ❑ PRO ESTABLISHMENT FARM TEST.WELL • U88_ W PUBLIC AIR ❑ ❑ ❑ CONDITIONING ❑`,.(OSPodR) SUPPLY INDUSTRIAL . D I COMPRESSED CABLE' x ❑ ❑PERCUSSION ❑ (OSpaafy) EOUI T ROTARY AIR PERCUSSION CAS LENGTH (feet} r DIAMETER (Inches) / a WEIGHT PER FOOT D ❑ ❑ OET THREADED, WELDED YES NO L XES NO . . _ . HOURS,, GPM ❑.BAILED. ❑- ` YIELD;(G P M )' _ T _- .PUMPrD -- �O`APRESSED AIR .. MEASURE FROM LAND SURFAEE-STATK(Specltyaeef) DURING YIELD,.TEST Itoot). Deffh o Completed Wsll ; in feet `slow Lond surfou: 1 MAKE LENGTH OPEN' TO AQ FER (leaf). 1 SC DET SLOT SIZE DIAMETER (Inches) ..-,.. ,•, IF,GRAVEL- Dicmelgr,of well •including GRAVEL SI SIZE. (Inches) FROM (1001) TO (feet) I, PACKED: _ gravel pack (inches): - DEFTN,d IAND SURFACE � FORMATION DESCRIPTION.'— ,,, • „ - _ d/sfencss fo of feast Sketch oxaet� /pest /od.of wNl wIM two pertrienent landmuks FE o FEET - - - - -- ..:.. ._.,,.,,_mod _' _.::�_ •�.�..,.e.,..:— .:.— ...�.. - — -- --. ____ _ __�.._ �.. -- _ - - - Q DATE OF REPORT W DRILLE gnatuyA)_ DATE COMP 1E RECEiVED. (MAR 2 5 105 PUTNAM r I f ' . . DE'P.�'. OF "Ouivey 1 HEALTH YORKTOWN MEDICAL LABORATORY INC. may. P.O. Box 99 321 Kear Street LOCATIONS: 0 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245.3203 Yorktown Heights, N.Y. 10598 01 BUTTONWOOD AVE., PEEKSKILL, N.Y. 10566 737.8777 245-3203 _ ❑ 495 MAIN ST., MT. KISCO. N.Y. 10549 666 3335 -f l rrn..r. re.ru vC I IC i..+ N/� L'Tpi"i A N• ':� °Y '1 AG19 q1/ 7 . LAB # (/ DATE TAKEN: — --� DATE RECEIVED: DATE REPORTED: SAMPLE SOURCE: REFERRED BY: - COLLECTED BY:* ys LABORATORY REPORT / ,, // mg/L. /- PV •% D ❑ ACIDITY ................................... / 1r % -A .......... ❑ ALUMINUM ......................:........... ............................... ❑ ALKALINITY ......................¢ ................... ❑ ANTIMONY ................................ ............................... �ACTERIA, TOTAL /mL ......... / ................... ❑ ARSENIC .................................... ............................... O' BOD, 5 DAY ................... ........................:...... ❑BARIUM ....................................... ............................... ❑ BROMIDE ................... ............................... ❑ BERYLLIUM ................................ ............................... ❑ CARBON DIOXIDE, FREE ❑ BISMUTH .................................... ............................... ❑ CHLORIDE ................... ............................... ❑ BORON ........................................ ............................... ❑ CHLORINE ................... ............................... ❑ CADMIUM .................................... ............................... ❑ COD .:......................... ............................... ❑ CALCIUM .................................... ............................... ❑ COLOR ....................................................... ❑ CHROMIUM (tot.) ............................ ............................... ❑ CYANIDE ................... ............................... ❑ CHROMIUM (hexavalent) .................................................... ❑ DETERGENT, ANIONIC ... ............................... ❑ COBALT .................................... .............:................. ❑ FLUORIDE ................... ............................... ❑ COPPER .................................... ............................... ❑ HARDNESS ❑ lv1PN COLIFORM COUNT/ 100 ml .... ............... ❑ IRON ........................................ ............................... ,9HFT COLIFORM COUNT/ 100 ml ............... ❑ LEAD ,................................... :............ ..... ❑ CONFIRMATORY TEST ... ............................... ❑ LITHIUM .................................... ............................... ❑ NITROGEN? AMMONIA - _ _. ....................................... ..... _ . - ❑ NITROGEN, KJELDAHL ... ............................... ❑ MANGANESE' ................................ ............................... ❑ NITROGEN, NITRATE ... ............................... ❑ MERCURY .................................... ............................... ❑ NITROGEN, ORGANIC ... ............................... ❑ NICKEL ........................................ ............................... ❑ ODOR' ....................... ............................... ❑ PALLADIUM ................................ ............................... ❑ OIL & GREASE ............... ............................... ❑ POTASSIUM ................................ ............................... ❑ PH ........................... ............................... ❑ RHODIUM .................................... ............................... ❑ PHENOL ....................... ............................... ❑ SELENIUM .................................... ............................... ❑ PHOSPHATE (ortho) ....... ............................... ❑ SILICON :....:...................... ............................... ❑ PHOSPHATE (condensed) ... ............................... ❑ SILVER ..................................:..... ............................... ❑ PHOSPHATE (total) ....... ............................... ❑ SODIUM ........................................ ............................... ❑ SOLIDS, SETTLEABLE, mt /L .......................... ❑ TIN ..... .......... ...................... mi ......... Pm ❑ SOLIDS, SUSPENDED ... ............................... ❑ ZINC .................................... R....�`1.6�....... ❑ SOLIDS. DISSOLVED ... ............................... ❑ .......................................... ......................t..1..... ❑ SOLIDS. TOTAL ........... ............................... ❑ ............................................... j. ............................... ❑ SOLIDS, VOLATILE ....... ............................... ❑ REMARKS: .......................... . ..... .:.�ih...!` ❑ SPECIFIC CONDUCTANCE .............................. ❑ ........... .............................gyp ................................... ❑ SULFATE ................... ............................... ❑ ....... . ................................. � !�rI{: >. r^.., ............ ❑ SULFIDE ............................... ...................... ❑ ......................................... .. .... .Q 'F..hi� ......... ❑ SULFITE ......... ❑ .. ..................0.............................................................. ❑ SURFACTANTS ............ ............................... ❑ .................................................... ............................... ❑ TURBIDITY ................ ............................... ❑ ......... ....................... ... _._ _ ....... THESE RESULTS INDICATE THAT THE WATER WA OF A SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED, THESE RESULTS INDICATE THAT THE WATER DID IIE AT SFAC C IEMICAL QUALITY OF. NEW YORK STATE ADMINISTRATIVE RULES & REGULA I K WA E ST DARDS (PART 72) FOR THE PARAMETERS TESTED. - > ALBERT 11. .PADOVANI M,T (ASCP) , DIRECTOR* / ®l4c)L & IgAfi Owner or Purchaser of Building Section Location - Street Ar,)" J14 w,� -� Municipality Building Type ell- Lot _/qrZM age6zrle-s- - Subdivision NameOF Subdve Lot # GUARANTEE OF SEPARATE SEWAGE 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 success- ors, 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 immediately, following the date of initial use of the sewage disposal system, 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determin- ati.on_of . the 1Di.r. ector, of the Division of Environmental Health Services "� " `ot' `the t'u'tnam l;ourity I�epar meat .of- Heal tij. as i;u -w4letiicr or not the "Lai-1- ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this -aay of 19 Signature _ Title Corporation Name if corp. a Address r �� -- - - - - - - - - - - - - - - - - - - - - - - - ------ - - - - -- THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED° GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST AE_ ° �- L - - - - - - - - - - - - - - - - - - - - - - - - - - - - i �f € - - r.- - - - - Division of Environmental Health Services, Putnam Coun epartment of Health bbAl Al ; roe N T Y / 13! Owner or PurcMaser of uilding 1 3h Section .-�-i.i.:.n-= :�e�'tti ��r1 .�LS�.:sS.o*�aw.SG.�+•- R''.�1: }`��,!. i:rk'�.i. -n :vrr::.,, °., - :^.g:�e. -: :.�.ss..�aw "`��?'�...`�..,. ",i:;:.'� "..�� '. .. :y..:;.- ..:�� ... . •.- Location - Street Municipality 7� Lot Subdivision Namel P A4Zj2 -Ld G 2 Building Type Subdv. Lot # GUARANTEE OF SEPARATE SEWAGE 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 success- ors, 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 immediately following the date of initial use of the sewage disposal system, 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 occu- pant of the building utilizing the system. The undersigned further agrees to• accept as conclusive the determin- ation of the Director of the Division of Environmental Health Services 6-..wt ,,- nerz:: Qr.:. ..,- ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. r Dated this -day of 19 Signature Title Corporation Name if Corp. Address "'R' x'ion ,¢GCS ; rU -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. r 11 N Gra GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST US SYSifM� - - - - - - - - - - - - - - - - - - - - - - - - - - - - `I - � � - - - Division of Environmental Health Services, Putnam County Department of Health PUTNArvi r0j DEPT, OF HEAL 1' 3 } *11 Am OwneLrj'o Purchaser of Building i Section ^Bl 11C11'Yl' -CCill ti "[aa: Location - Street Municipality Building Type r x- Lot Alen Subdivision Name/ Subdv. Lot # GUARANTEE OF SEPARATE SEWAGE SYSTEM I represent that I am wholly and completely responsible for the location,,,wor"anship, 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 success- ors, 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 immediately following the date of initial use of the sewage disposal system, 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 occu- pant of the building utilizing the system. The undersigned further .agrees to accept as conclusive the determin- ation �f _tr.e...Dax ?cto.r_...o.f..tbe_ Division of Environmental Health Services ot. ttie- rutriain�Launcy".i�o iari merit `of 'riea th- a ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. 77" Dated this //..- of + 19 Signature �. Title Corporation Name if corp.) Address - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE __.. `FTQlA. ' - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �, ►,h? y - - Division of Environmental Health Services, Putnam County bw�..Ai p ,.,.,fyHealth IPT. OT" J EEL fi -a , • /fib p,, ° '�- � - PUTNAM COUN'Y" � r F� �� b �.r Division of, Enw�or►ment p � CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL S "i Uocat d at SuDtlivision i OA owner /Address Building Type �' CfS/n6�cJTifL Lot Area ' 2 Number of Bedroo P1 ms Design 0w G /P /D 6'0D r ` 4 Separate.JSewerBo System �to consist of / Q O To ,be constructed Eby ��cLo4 CBMd"T': CO. s � Water Supply Public Supply From` N k 'Private Supply to be tlrihed j6y, ' -� - Address." Other Requirements I represent that t $m wholly and completely responsible fog the daSif above described will De, constructed• as shown on the approved amend County Department of 'liealtn, ,•and that on completion fhe'reof a" be submktetl to`- the3 :Department,•.and i written'- guarantee will tip ,place in - good, operating condition any; part of. said sewage drips ance of the ,: of 'of 'the Certificate of Construction :Compliii i will be; located ai'`shown on the appiovei plan and drat said`well 141wl County Department of Hpak < f� 4x Date a y .Wsigne � A�dreu APPROVED FOR CONSTRUCTION "This.appioval explres one ye ed revocable for ca se or may be amend or modifietl.when.considere ,requires al new .erW, proved or disposal -domestic n. _ G stn ey M1c , E'PARTMENT OF HEALTH' Permit r I. - ia/iti Services C.ar//lel, N' Y fO512 or age -2 ',- Renewal iQ r Revision n - ` 7 �r Date -Of Previous Approval � - H i� a „'.k t7 Fill Section Only 0 u r.V P C.R D �NOtificationlRequired t' Septic Tank, antedZ�C:F y Z -� " A[Y .4R.1 fi�n`TtO,el' T,Po-t'�✓(/° f 4 n e Address 1. �f p„ 1. t locatton Jof the proposed y'sterill 1j that the separate sewage dis oral s stem R674 to and ,in accortlance with thetstandards 'rulecan "regu a ions o e, -,-Putnam i irate of Construction Compliance rsatisfactory.to the'Conimissioner ot.Healthwill shed the owner his siictessors; Heirs or assigns by the,liullder; that said builder will stem during ,the period of .two. (2j years immetliately; following thedate of the issu =' the' oiiginalsystern _orany,repairsfhereto;'2) ihat;the'drilled well.described above I. tilled in_ accordance with the'. standards,. rules: -and: reyu a ,qns . of the :Putnam ` ' C niche date _iisued'uriless cgnstruction'';of the buiklir►g has been undertaken and is t ssaiy by' the Comm od�e► 'of Health. -Any change - or aiterat ion of :construction va9e, and /or =priva w Cei =wPPly only 1 Date 1•"•-i` � ♦ . - PT . � - af' r. N: -r?.6 ...c. r... .. . ♦ Y i'x•`� -.Gw r�..�r4- ...;a -� •:... .._ -._. .-. X'v« .++.� "T�r . i -. -�.. -.. r• I` TTTIL �j - Yes No Coirmcnf. ,Proper.•t.y lines or corn•rs found . . C . a C _ Gan cstit�r to house loca.t�.on . . . . . . . o Will drivcway • need cut . . . . . . . . . . . . Must trees be removed -note these Is sleep hole representative of entire SDS area Addi -Uanal deep holes needed. . . . . _. Sufficient SDS area available considering driveway cud;, house location, separation . distances, etc. DEEP HOUR, DATA , Dapch I -later elevation: Rock elevation: • Soils description: ' — Pate. FIT -NAL SITE Insp. by: Houso located mhere shot-,,n on 'approved plan • . SDS located where aporoved . . . . . . . . . Irng ill of trench m -G s red Width of trench aver_ae l of `.:.j:rile:. 12 -Re _n- Lrenc..::� Room allowed 1'or e'xDansioii trenc -ls -� . °--- o'._� Over 50 ft. from s a-mp,l.:atercourse hatural soil not .stripped or SDS area ._ : .� ._ - •- ��,�.�:._; - wu-ieclessarily graded . . ... . . . . . . _ • 10 Ft. maintained from prop.line. and 20 f-t . from house . . . . Sepoxation of trench from house, well - -etc. folic »s' plan . -. . -.- -. .- - - - -- .- e o - e -o -a - - ...- -- --- - - - - -- . -- -. . h1rai3ber of bedroomns chccl:s . . . . . . . . . Stones, brush, . stui:ps, nibble; etc-. greater than 15 ft. froin nearest trench � 15 Ft. of peripheral soil horizontally from 'trench > .. - . . . . . . . . . ... . . . . . Aev JLUZCtion boxes properly set Cot�l.d surface run off from drivejaay, roads, ground surface, etc. sham -,el near SDS . . . , are". . . . . . . . . . . . . . . . . .. Does lot drainn:� c anrcar O.K. �i.n area of SDS % •,� Ca"CfUt cJ C-� � ? FINAL GRADING OF SITE ACCEN>:'1T F . r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES c�- C.(S:•li^v .I.a ,c-T Vn sTx •van.. i1- v:^..��:9•A'•a- v'r.�.�(M Q.h.Y -r wi+:+•••..o �v:`�.f� -t*a �'r'r•va.�F_ w�� ?C'�`y?-�ID:"'.a%� <G :/:aK veiit4' -.R.n G'wa -nf. :,w ::�:fvaM�: +�Yw r��a�+VwVr:/W wY.•. -• Date Re: Property of Pci-L j 4 MI) r (-, G Lrm', n A Located at oc<) ;S� re.e;t. Par f c) C• (T) PUVAYA A I%4-LLae Section (p Block - Lot / '- Subdivision of e. � ? r(-)n e,01 (as Subdv.,Lot # Filed Map # JS 2 Date Gentlemen: This letter is to authorize a14" LL /, A4 a'duly licensed professional engineer 61--1 or registered architect (Indicate to apply fora 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 system�or syst•emsYin conformity with the -provisions- of�Article�l5 -or•a 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. of NEW y. 5�P � ��P,f Very truly yours, \ , Z" l Signed Countersigned: Owner of Property Zo # e Address Address Town /F 0 z— Z elephone Z Telephone °„ 0� 6` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES a0970 r' .FIC $ " I7PUG rr - ,.v ; ...,.._.. ..... �� . . ,..,. -, DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner fug Mao &r C#,,y1a,4 Address P¢TR /OCC ✓•acc,��- Located at (Street lioo '. i- ica e nearest cross street) Municipality. /TAM /%,gG �y Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION apse UFTETto Water a er ve No. Time From Ground Surface in Inches Soil Rate .Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 /0 :0s' 10.•7,7 ZZ. z Y L7 3 7_7 2 1o:z7 lo .s-7 .30 7,y z. fo 7_ /S, o 3 io s7_ ii.• z 7 30 4 //: i7 1z: S9 30 z.x z rhv /7-3 5 1 /o : 20 10 : ya' z s' 2_f z 7 ' 3 81.3 /2:/J, 3 o z 2- /�'_ /;1. 3 5 27 3 So 3 3o zjs � 13.3 a 4 / /•'�S' /Z , Z s' 30 Gl`� �� i� �� ..,� z(o Z. �� D r M- Afy DEPT. OF HEM.'.. §i'a Notes: 1) Tots 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. b- C . , - d* n TEST PIT DATA REQUIRED TO.BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOITLS ENCOUNTERED IN TEST HOLETSy }y,T Y ... ..•LyY ..i� � Yi� SSnC.L` etat.,F.��l }T.n'l, .oh•S�::L� 11 0�1 ^"6�.. _ ''.":2'u'�C'_ -f ., l..0 _. cx��T'• lnlA M-xi..KY� .t...••/l'.(La'F+.'•`� G.L. 611 1211 1811 2411 30" 36" 42" 48" 54 it 60 66" 72" 78't ti 84" 7 f0 i L INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED 4 , INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED `✓�� _ .T.`�TP. _-• ® (- ?'��:> �!''':.'. - .-. DESIGN Soil Rate Used Z&7-.o Min/1 "Drop: S.D. Usable Area Provided ..s'000 S� No. of Bedrooms 3 Septic Tank Capacity v v Gals . - ,L Absorption Area Prov ded By yZ9_L.F.x24" ei Z ? 0.13. ALL 3 5/o C. Y. lvame GIJi�C,��yl F7 Zg-1 g/L signature Address fFz) ogo �,� SEAL ip Al THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: ° F�oFESS�o Soil Rate Approved Sq. Ft /Gala Checked by Date 579 (/gGgNr /00 Q S i.ocgNT v GOT�Z ExPANS /ON �'eE'Q 4fO— o —�= — — - Tdo �pl�SGOC� ��OAGlSEO 3 .�iBO.CGIAisJ cCSE e I P �.sco O/A /KG lqi OO p vT 2E�7- a I i r i i 1' �1 FT -1 1 Z' PD.Q <.GG �3QJc -r. O O /J�C.iLPPT /N� TGL�'cvES of - &¢alth . -SGa�� YQ ��•[ � CGWGLETE _SLvT,c TA.✓C !. SC.9LE' fiat /zovrgL / "= ZO - � ❑ O�EP TEST f%E' O YI�ECC nam oun 9 Division of Lr' : "'onm °ntal HoaltYt;Serviaoe " c formanc ") R1th i Approved nr,; of iipi—1 the - �y C :.c . _ ; -?z �artn` � 4 it 6 , O Gbi✓FO.P� TO / y(�T�L/' I/✓�E of �T'✓`TE T BF+ /N3` /gCGEO l -� .Spy /Fic�aTit+'�S �P' .5v� .✓ Co BY uvry T.sG /°v `��.v NE.xr. �il.�Tis9ENT. 2 �Ei»0 ✓E iILG TC6L°S !v/r✓ /N A7 J.$�. /I 3 A �q� � S �GY Fi�al�ti�0 Gv.�ET ES!,.eot -9N •c�� ,v /Tn� APT ^fC'%� .CE�.ErO FeIC L'Q:'�S7.PUGTiN✓ Qe: »✓E 3 � �� •9.! 4 CGV✓�P.rTOr ro ..✓sTACC sEOTC To Ftacv By y cvuTTr 5 .�.w cos �t./.✓e Gas �2 � .Susoi ✓is o..i �i;�,✓ ..es meTz f RECEI SEPTIC DES16N fl1AR 3 C f UTf,IA, ",A C DEPT. 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