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03620
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PUTNAM COUNTY DEPARTMENT OF HEALTH
U1 "^ Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Mast Provide
P.C.H.D. Permit N
Est L::'14S"ft -U CTI G`: C12.hiP !&NCE,- F 01: SEWAGE P 15PO 5AL49
Located at 1� O
Owner /applicant Name /"aq' 1m /�h y 4'�O/ �rmerly
MaWng Address �/ / /, �' ed r14. —zip /0
Town or Village
T. Map Block —_Lot %
Subdivision Name ,0%1 14'& Subdv. Lot p D'
Date Permit Issued h ��
i
Separate Sewerage System built by '� `J°j� c° Address 6133 i "2 iI �� N. J
Consisting of / o d Ci Gallon Septic Tank and g�tJ o F 2 n trL Yom°
Water Supply: Public Supply From Address
or: Private Supply Drilled by-Al Aol Address
Building Type �! Has Erosion Control Been Completed?
Number of Bedrooms �_Has Garbage Grinder Been Installed? G
Other Requirements
I certify that the system(s) as listed serving the above premises were
of which are attached), and in accordance with the standards, rules and
Putnam County Department Of Health.
Date =�sJ by_
Address S/474n,
Any person occupying premises served by the abd've system(s) shall promptly take
conditions resulting from such usage. Approval of the separate sewerage syster
available and the approval of the private water supply shall become null and void
subject tt odifieation or change when, in the judgment of the Commissioneh
Date
!Rae shown on the plans of the completed work ( copies
8 wi the filed plan, and the permit issued by.the
r'
P.E. R.A.
c ).'v t l.iconse No$ a%"
�be necea ry to secure the correction of any' un unitary
i ,i nd void as soon as a pub('. unitary sowir,.ppcomes
'water supply becomes available. Such approvals'.ara
revocation, modification or change Is nscesurrGy.','
Title
nA PUTNAM COUNTY DEPARTMENT OF HEALTH
_ -- � ._ itivtrlltin � j�v�oamental �eWth
_ on CERTIFICATE F COj"LIANCE
ION
Permit M
CONSTRUCT PERMPP FOR SEWAGE DISPOSAL SYSTEM % -
Located at Ale e a4' 5 l!- %i'_7 Town ar Village
Subdivision Name lG'i'g MG,n ; _— 0U Solid. Lot N k Tax Map �¢ Block `3 rof
d
Owner /Applkant Name Renewal_ ❑ Revislon ❑
P, �� �J�7 i r�
y G d y)1-_e-e.7'_ Date ofPrrevlous Approval
Maig Address Town ,A , v oc�,
ZIP
Bldld6ag Type / 1:2- -5 A. Lot A Q �6 4r
Fill Section Only Depth Volume
Number of Bedrooms Design Flow G P D 6 ` `' PCHD Noti lestion !s Repaired When Fill is completed
Separate Sewerage System to consist ofd V Ica �' Galan Septic Tank and
To be constructed by Address
Water SuPlibl . Pub11c Supply From Address _
or: Private Supply Drilled by _Address _
Other Requirements
I represent that I am wholly and completely responsible for the design and location of the
above described will be constructed as shown on the approved amendment there to and in
County Department of Health, and that on completion thereof a "Certificate of Co
be submitted to the Department, and a written guarantee will be furnished the o e ,
Place in good operating condition . any part of said sewage disposal system dui the
ante of the approval of the Certificate of Construction Compliance of the orig al Sy
will be located as shown on the approved plan and that sold well will be installed in cpr
County Department of Health. F
Date y— Signed V
Address 1 9- 2 ems) r%
APPROVED FOR CONSTRUCTION: This approval expires t cg
years from the date i
!evocable foricajuse or mayAe amended or modified when c4 idered necessary bd the
I.Md 1) that the separate sewage disposal system
. ce with t ards, rules and regulations o e u nam
oen III Story to the Commissioner of Health will
tticcessorl;, Qpir r a ns by the builder, that said builder will
�d P1.0y (2f*9 s im lately following thedate of the isfu-
ggr it any;tepairs fp to- that the drilled well described above
Whh'the., ndaYa I s and regu as : —Pions oof the Putnam
_P.E._ R.A.
he building has been undertaken and is
lQ►��li.a 4 TA1T TTT1l1TT
rL ►�
W
Wr.LL l,Vr1rLr�11V" ATIrvlti
DEPARTMENT OF HEALTH
Env.i:ronmentaZ .Healt.I�.:.ervices y
PUTNAM COUNTY DEPARTMENT OF .HEALTH
Office Use Only
-.yam.• .w. ?� - ?�. "'Y.
WELL LOCATION
STREET ADDRESS: 7OWNIVIL13171CHY TAX GRIO NUMBER:
Ad 3—
WELL OWNER
ADDRESS:
' o
PBIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
gRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
0 BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
'❑
/
YIELD SOUGHT gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGE° gal.
REASON FOR
DRILLING
KNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH 00, —ft.
STATIC WATER LEVEL � f
DATE MEASURED
DRILLING
EQUIPMENT
ROTARY O COMPRESSED AIR PERCUSSION ❑ DUG,
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING. )kOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH / ft.
MATERIALS: ..STEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE ft.
JOINTS: O WELDED .®.THREADED ❑ OTHERR
DIAMETER 'r in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE OTHER
WEIGHT
PER FOOT /"7 _ lb./ft.
I DRIVE SHOElPES ❑ NO
LINER: OYES 1[IO
SCREEN
DETAILS.-
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED? ..'
FIRST
-
❑ YES- 04, .:..
SECO
GRAVEL PACK
❑YES
❑ NO
GRAVEL L
SIZE:
DIAMETER
OF PACK In.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
t
M HOD: O PUMPED tests were done is in-
COMPRESSED AIR ,formation attached?
BAILED ❑ OTHER ; ❑ YES O NO
1P1ELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Pear-
i ^g
Well
Dia-
Deter
FORMATION DESCRIPTION
CODE,
it.
ft
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
J�
�QQ
WATER. ❑ CLEAR TEMP. .
QUALITY O CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES ONO
ANALYSIS ATTACHED? ❑ YES ❑ NO
�..d
STORAGE TANK: TYPE
CAPACITY r U GAL. yd
PUMP INF MATION �,,
TYPE `� APACITY
MAK DEPTH %mod r
MODE 4//7X'-1,iOLTAGE,3'-30HP�
WELL DRILLER NAME
Fr
ADORESI-rK SIG&MRE /)
/ /
jL C7Z'3�^�'t'
Y®rk6own Medical Laboratory, Inc. LAB #
321 Kear Street :Date Taken: __.h3`728/8'9 Time: 8.30 -Am
Yorktown Heights, N..Y 10598 _•Date Re' d;_ : g A
..,�� F�-J
Director: Albert. H. Padovani'M. T. (ASCP) Collected By: P. SOLLA
Referred Byc
T 1 Sample Location: KITCHEN TAP:
SOLLA, PALMING. i
203 WOOD STREET
MAHOPAC, NY.10541 Phone # 528 -6763
Phone # f Sample Type:
L J Repeat Test? _ I (check one)
LABORATORY REPORT ON
THE QUALITY OF WATER
INORGANIC NON- METALS
(mg /L) MICROBIOLOGICAL (CFU /100mL)
_ Acidity
GENERAL BACTERIA
_ Alkalinity
GE 9
_ Chloride
Standard Plate Count
_ Detergents, MBAS
_
(CFU /1.OmL)
_ Hardness, Total
_ Nitrogen, Ammonia
MEMBRANE FILTRATION TECHNIQUE
_ Nitrogen, Nitrate
_ Phosphate, Total
//'Total Coliform
_ Sulfate
_ Sulfide
Fecal Coliform
Sulfite
_
_
Fecal Streptococcus
METALS (mg /L)
_
MOST PROBABLE NUMBER TECHNIQUE
Copper
Iron _ Total Coliform Index
Lead
Maiig &rre -se _. __.�..._... :_ r e:car'"Co`liform" Tnciex`-
Mercury
Sodium KEY FOR TERMINOLOGY
Zinc CFU = Colony Forming Units
MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
N/A = Not Applicable
LT = Less Than (< )
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
otable
Non - potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
HNO3
HC1
_ H2SO4
_ NaOH
_ ZnOAc
_ Na2S203
Other:
LE
40C
_
GT
40C
_ pH
LE 2
_ pH
GE 9
pH
GE 12
Other:
REMARKS /COMMENTS (For Lab Use) IELAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH N YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT DR KING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
x�� 2 /86(Rvsd7 /87)RWE
Albert H. Padovani, M.T. ASCP), Director
v
PUTNAM COUNTY DEPARD9W OF HEALTH
DIVISION.OF ENVIMNMENTAL HEALTH SERVICES
-... e+. '. _- .....� ..3� .. .. _..._ -.. r ..... -. _ • . - - .M. c. -. .. � 1._u.+.• VI�:�_��. •. 4}`��- � m.. �-pu�t .,_, +-�. Yih IY.• .� ... - � .. -era r✓
1 _ �
• � -. -.. .• yoV %`.. �.r�.,...w.. -•� ear.:'.
Owner or-Purchaser of Building Section Block Lot
Building Constructed by - - --
Location - Street
Municipality
Building Type
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEMU 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 immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made -by me to, such. ..system,_: -except- where:.the. failure- to.. operate
caused' -by,- thi F w lifW7 -0.f Ii�iglije'h� act of fie occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environirental 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 ut' izin
the system.
Dated this d''of 19�
Genekal 96ntE4ct6r ( er) - ignature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Title
g___ - z
Corporation Name (if Corp.)
Address
.
4.
- Y ,a
I QI`i1 CpG ,: ;DE PARTMENT O.F HEALTH , :
3. ,
��. � Division of Environmental Health. Services
s —w
a' 4 b"� _ ;TWO ,COUNTY CENTER CARMEL' , N Y 10 512 (91.4) 2 2 5 3 6 41 I 11
'�,w O4� l; APPLICATION TO CONSwTRUCT. A WATER WELL -"� '
.� C �'P T� # FXVT"".,`.� �'
+� r;�. X2 t < t , f u xa 3' - °'.'.,. a ., ..;,+ 3'+r Csn i :'.`,' _'` h +,. a k
P HD;' ER1KI "
� w -'
WELL LOCATION
.'.- Street�Addr s" Town ilia e Ci y '" ;Tax Grid Number "
t 5
�
'
o�... r '. '� fl`7� A`,J
r •
d k. IW e.
WELL OWNER
N e , . ,i 1T1ng Addre s
r;--te °. 1-1 I
Y
t
�._.
/a� /�_ =_.�_. /G'GYl�Oi�- 0�//,._� DPublic..
_
"
jUSE OF WEL-h
-SIDENTIAL ❑PUBLIC, SUPPLY Q AIR /COND; /HE PUMP : ABANDONED
1 !`primary
®BUSINESS: O FARM p TEST /OBSERVATION tip OTHER (specify
2 .secondary
11
-0 INDUSTRIAL b 'I""".— INSTITUTIONAL O STAND BY, - ®4 - ;, `'
s
r ,;
11 .." fs :R 7, _, . k . ��: _ 77 - . :� ,
, i t �$n �4Y e - t £ :i, d r
AMQUNT USE,
, �, . k- y e.. s f � %' , TS. :; . W� 1 : .f ,: .+ e i -
x ^cj /4� PFQPLE SERVED a /EST : DA -ILY USAGE ` `4 `
OF r
I I'll
YIELD SOUGHT, gem 1 � , I gal
.. ,. :4 i_.._:,,., .:.. sn.. .'.
.., \ .. -.t ... .. xw., a...•t._ " -._ 1111 *.. ...r.� " Pr?x"rM';
REAS0W FOR ''
; E--l-1-1- : SUPPLY ;; " D�PROVIDE ADDITIONAL `SUPPLY= ®TEST /OBSERVATION
''DRILLING, ' ,',
s•
_`- 0REP,UCE'; °EXIS.tIN,,G.•'S,UPPLY- . .' O >DEEP.EN,: :EXI-STING', :WELL, ;. ' '
r,..= ,' 't,.
DETAILED
,' -, :, f -- s
;, <. 3 1
:REASON FOR
:DRILLING
y :`
��
r
-- X, T
WET L TYPE}
• f k, ySt''E ..F ,y ,f .' CE O --,
KILLED DRIVEN ' ®GRAVEL ®QTHER I
0,;,—,-, i. . _, �; :c. "f .. ... ..
_,. ._. ..- _.
f .[DUG 11
,...a.r .. _,.;,, :I
.. .rr. 4. t� -,.f �;v k . as:: S a.,. s.i...,. ,r...� , z;....t,.......,..1. �. :: , 11
_ _... -. . - ._1111...,._11.11..._ .._._- _-- ,__- ....-- l -. -.. .._ -'�
WELL r SITE SUBJECT TO' rFL00D3NG� t ,,a� k t k <' x'YES } j `NO.r A
WELL IS`LOCATEDaIN A MALTY SUBDIVISION NAME OF SUBDIVISION
�/, G� O
t °... ,T 4
. R! - �.
1. , ..,. .,_ - .,_ .. Lot No
_.
} ;?'E
TER WELL CONTRACTOR Name' �'✓' >�p ..- x Address G -ra
ff r:'
1- PITRT.TL'_.WATF.R Si1P :PT.Y. :AVATT.ARLE Tn SITE_. r. r, ._._ YF� . ` ...� NC1 - ; :: A
'ClA, ,VP r--Y, -1, . KH P- -1C' AU.C* I -- ,, : } , . s .Z : :. ,� ,1MW .,/ V 1L/ 1.11 2 T S L`, Ar;
j ``STANCE TO PROPERTY FROM NEAREST WATER'MAIN ,
r 7..•fi .d '� ti�1 ' L
r �'ATION-SKETCH & SOURCES OF „CONTAMINATION PROVIDED F
` _ ON -REA' OF THIS APPLICATION ON SEPARATE SHEET i.
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PERMIT . - u t - F 11 � 04 Y , , , -CONSTRUCT A `6VATER .WELL
This permit to construct one water well as ;set forth =above,= i s granted uncle 1.
provTSons of Subpart 5 2 of Part 5 of the"'New York State Sanitary Code, a
provided that within fhTrty "(30)=days of the completion o.Xwater weld cons
thef appl scant shal 1 _ r n Y z
� - f 4 A' i i } _. C�
a 1a a , u4 `Y' �,l r, � ,. , �, `ir 1', oft t+W R �Z D �, r q y 1.: , j
`- x 1 � Pump <the well Kunti 1� the .watery i s c, ear ; " -- -� �� 1.
2 Disinfect the :well `T n accordance with -"6 requfx Ments of ,the Put
ry i ,. a j" k: r r,
�� �. County�Health Department attachedto th�TS permit w.
' 3:.. Su- ,t a..:Well? u," , on Report on a form provided by .the _Putnam
1. i
Health Department
x
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F.AW2010
PUTNAM COUNTY DEPAM= OF HEALTH - DIVISION OF ENVIROMMAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SPMGE DISPOSAL SYSTEMS
REMEW SHEET— - `CONSTRUCTION 'PERM ET
DATE REVIEv+lED : ! L
SC) c C'- A C1V0C)6 ST BY: (--LL/ 4
(Name of Owner) (Street Location)
cams, S
YES
NO
.x
7�-
LF trench provided 6�
required \3--u a
60 ft. max.
Parallel to contours
100% e-xp.
�
��J
�vl fS3.JV
/J/7 S /q"3 `Z)7-i4 q f)E�� lzcfi /ova
FILL YSTEMS L, r a c, %
?�
cla er /o�vg suwv
10 f �v fJ C �9 cr
f it n - tes
no s
x
depth gauges
100 yr. flood elev.
?�
200 ft. reservoir, etc. Li
150 ft. trigall /gall.
DOCUMENTS
Penui.t Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc
(3) Fill
cd
House Plans - Two sets
Well -lei permit; PNS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Pe---nit R & D)
Data On DDS Plans & Permit Sage
REQUIRED DETA= ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flew
Fill Profile & Dimensions - Volume
D or(g_ ;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction ..Notes -(grinder rate)
Design Lata:`perc -aria '�epresul£s`•F��;� i 9�-z
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shown; gravity flow,suff. size
If PmVed Pit & D Box Shown & Detailed
House, -No. of Bedroans
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sever - 1 /4" /ft. 4 110; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake Unc. expan)
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stormdrain, piped watercourse
10' to Water Line (pits -20')
50' intermittent drainage course
Septic Tanks
10' fran Foundation; 50' to well
15' Well to PL 9
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
,. -,.:.. _.... �.•..__.......... �...:.., �.....,,•..,:;�.,- �T�,.SI'.�T.. -tax �. �- ���: Ip; �1T� 'l��TTAL-= Hex,Al;Tix::�.r13?t %•-ICE- .��:�- �.:. ..�..�,. _.., .. �,...._.._.. .,_ _. .
Re: Property of
Located at
(T) A Av"v K� 'v Section 14 Block �S. Lot i
Subdivision of_ �j GC���O %d /G e- /� U
e i
Date
Subdv. Lot #
Filed Map #
Date
Gentlemen: �� This letter is to authorize �a� 2]� / / J ✓ems
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
CJ Y:e�*:�O?:- i± c � '1� •."��t�cr and �� - sup6rvise -the c&nztrz-:c3t. 3•i
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.
OF NEW Y
Countersigned: �� o
� FgAPoCIS �.G ?fi
P . E . ,X.A .,
Address
48915
C/ly
Telephone
Very truly yours,
jCLI,,,7
Signed
Owner of Property
Address
Town l
3__�>--5- c/, 7
Telephone
PUMM CCXAM DEPAmimEw OF REAL11i
DIVISION OF ENVIPUZIENTAL HEALTH SERVICES
DESIGN DATA SHEET-SUBSUFACE SBqAGE DISPOSAL SYSTEK FILE NO.
Located at Street) Sec. Block Lot
(indicate nnest cr7o
e; eet)
Municipality Watershed
SOIL PERCOLATION TEST DATA REDUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre-Soaking Date of Percolation Test
HOLE
NUMBER CI= TIME
PERCOLATION
3
PERCOLATION
Run
Elapse
Depth to Water Fran
Water Level.
No.
Time
Ground
Surface
In Inches
Soil Rate
Start-Stop
Min.
Start
stop
Drop In
Min/In Drop
Inches
Inches
Inches
�12
21 J16'
'30
4
5
4
0
2
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 submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
3
4
0
2
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 submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT MIA 16T)UIRT.0 TO .LIE SUI IMITI'l-D WI111 APPLICATION
DESCRIP'T'ION OF SOILS ENODUNIERED IN TEST HOLES
i
DEPT9 HOLE NO. HOLE NO. HOLE NO.
n
s
3°
4'
5°
6°
7°
8°
90
10°
11°
12°
13°
14°
Z JS. k' �;N ._
..
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: �fA DATE:
.� DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area ProvidedC
No. of Bedroans5 Septic Tank Capacity gals. Type
Absorption Area Provided By L.F. x 24" width trench
Other
OF 14 EW
Name f Signature 'W��:
C� t
Addressf
FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq,ft /gal, Checked by Date
I;.
FINAr SITE�DISPECT7 N Date -A�
In —pect s
V, .
crVNER
;C3T:.CN
IX,
IT7. ECL
a.
b
5. S = 1/32 " /feet.
r__ f ,�cr =-- 1 i r_ - 20
10 G.
e ?n
8. Rc= al! c a~ cr Er--�ris i cn, .50%
Size c= c =-;� 3/? - •rlt di arEel--
,�iP�� DISrC:Srr, P9E?
a" SJS arm 1c as per acnroved clans
1-4-t
b.
F=: 1 sc—c-Licz - Data of placam--Ilt
2:1 barrier . r W=.d gVC- .DFnii
I
c_
Iat=,zl scil nct string
I
d_
Stcne, bry" etc , Cr ==ter t_nam 15' frcln SDS Zar.
}�-
e_
100 ft_ f =a:, water ccur= e /:veI lands_
I
EF,,,5!C-Z- DIEPC:SAL S"fS
c. Eenl;c tint s_�-- - - 11000 1,257
6. Cvcle w_� __ by Esallth De ::a -ant
b_
Senti c lE el
I I
c.
10 =--c-'t
\�"iiCEr C7" be_ =5 "� I
Q"
\• 90,3 r.r c e: -- t }•• � 1 4.50 hand
►.C7 ��•. -r C_�_.CLIL. 4i_�R_'_ 10 L =. CL
I I
e.
DSO_ � �L-I' �3`+ EGA ' -
1• All c,�T ± e at .wr,_ elevati cn - TNCt�'" t =_=
NI k
2. Prote----ti balc:Y fm-es-" I
I
3. M? irm= 2 -f- Cric_-^ :l sci l het een bcx and i'`:c:?e5
f.
= --
1.1�I'TCiV t _" -" Drcrerly se--'
C.
- I
? L�Tc =-? rte_- =._.r. - L_-c =`-, ; r = -_
"
2_ Dist-E-:rica t-- Lam.
c 'clan
-C='
L • l7i c -1 nC? �_r to cantar I
IT7. ECL
a.
b
5. S = 1/32 " /feet.
r__ f ,�cr =-- 1 i r_ - 20
10 G.
e ?n
8. Rc= al! c a~ cr Er--�ris i cn, .50%
Size c= c =-;� 3/? - •rlt di arEel--
I
1G . DCD Z c-f c ��r� in t=ench 1? " mint*r�`n
I �i-
1. Size of C =m c =—.ter
2. cw `n-Ic
ti A j II, Vic�1 /audic
•
~cCraccih-!
I I
C PL'•IILD easily °_ iGc:li?OZe t0 Crace
( i
6. Cvcle w_� __ by Esallth De ::a -ant
I I
eS t? Trctc� =1Cw � =r Cr �e
I I
Ect7r2 1C�=-=- rer anDrcvei p1a_ns_
\�"iiCEr C7" be_ =5 "� I
• V. �Yr .. -• ..
a" w lcc =t -- cEr arcrcve plans
b. Di .ta_nce f_ '5- are= mea-- sure3 ft.
c_ C =ina 18" a: -,c ara -3e_
C. Surface GrG_-' - arc=d well GCCaDt hie.
a. EcY2s prcrer_v crcut=
b. A ; ' Dices r-- = E:-'- i y bGc i11
c. A? , pines fl- ush with insic.e of hex
c. E=d't =ill irat__al cent =?ns stones < a" in diatrete=
e_ C.2- -tain drri-7 installer acccrdinc to Plan
f_ `' �?P_ Cie? aut_all vrctac = & dir.tO E`!15`_SvcL�rCCLt'3
C_ F'Jct =na crc.'_:'= c ar
G'_SC'1cLCe vav t =CCR CDS c=
h- .C.'.;r a-C° wet =r Crotect"icn adec ate
1_ i _1751017 CC: `! DZCV 1GaC CP SlarCS C..aZLE-r tj -R 1a3.
r O.
2 -3 — J;? - so a— ) ba. v C)
n
2• Fv,
YX 4,p
- �-,7w
eoo
is