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BOX 29
l
*, _
. , IN
16 INA;
. '. .0
03767
Rte. „.3/'86
.:: CERTIFIC OF 1
Located st �
:i
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
P.C.HX. Permit 8 s /-� - � {{
WSTRIICTION COMPLLANCF FOR SEWAGE DISPOSAL S
YSTFAL
f _ Town or Village
T. Map 7 Block Lot ,
Owner /appll N e Formerly SubdivTelon Name-: s6wv. Lot H r
Ma in$ Address ri V .P /b rG Date Permlt Issued �� '1� • y i
Separate Sewerage System built by ! G tr -O.� L Ldo %i Address -12-S' ��'• a �O`./� _67 Ar
Consisting of �� Gallon Septic Tank and 4 .64 4 P' 2 •� W� d C t �91�/�cS
Water Supply: Public Supply From / Address
ors Private Supply Drilled by /� � !LG f' 30•� Address _- 14%1`147411V ra
Biding Type �� 1. d G" H" Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Requirements rl13el 13, el. %
I certify that the systems) as listed serving the above premises were constructed essentially as shown on the plans of the completed work I copies
of which are attached), and in'accordance with the standards, rules and regulati ordance with the filed plan, and the permit issued by the
Putnam County De rtment Of Health. Pitt OF
11 Date 4 3 Certified by 1•p P.E. R.A.
nr ` sG /
Address fr ! ��o�
l.iesnq No.
Any person occupying premises served by the above system(s) shall prompt
conditions resulting from such usage. Approval of the separate sewerag
available an'd the approval of the private water supply .$hall become null ai
subject to modification or change when, in the judgment of the Comin.
t
Date
I
apsury to secure the correction of any unsanitary
void as soon as a pubt% sanitary sewer becomes
supply becomes available. Such approvals are
tlon, modification or things Is necessary,
Title 10'1�
n Kl � �12AV-Rmzcl.
DEPARTMENT OF HEALTH
ivy: iori Of Ert virchmerit9l
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
'STREET AOORESS. TAX GRID NUMBER:
18 Angela Drive Putnam Valley, N. . Y. TM 79-2-22.15
WELL OWNER
NAME: ADDRESS:
Richard & Lorraine Delorenzo 18 Angela Dr. Putnam Vly
❑ PRIVATE
1 ❑ PUBLIC
USE -OF WELL
1 - primary
2 - secondary
04ESIDENTIAL ❑ PUBLIC SUPPLY - ❑. AIR/COND./HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION - ❑ OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-By ❑
AMOUNT OF USE
YIELD SOUGHT _A� gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY []TEST/OBSERVATION ❑ADDITIONAL SUPPLY
W SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH .211-0 ft. I
STATIC WATER LEVEL ft.
I DATE MEASURED 12 16
DRILLING
EQUIPMENT
G.,ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING Q-OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH ft.
MATERIALS: R-STEEL ❑ PLASTIC 0 OTHER
LENGTH BELOW GRADE ft.
JOINTS: OWELDED &THREADED OOTHEIR
DETAILS
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE 94THER
WEIGHT
PER FOOT Ib./ft.
I DRIVE SHOE. 0 YES O-NO
LINER: 0 YES LQ.NO
SCREEN
-DETAILS.
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
0 YES 0 NO
—HOURS'
.8 ECO NO -
GRAVEL PACK
0 YES
0 NO
GRAVEL
I SIZE:
DIAMETER
L OF PACK in. I
TOP
DEPTH —ft.
BOTTOM
OEM - It.
WELL YIELD TEST It detailed pumping
METHOD: 0 PUMPED tests were done is in-
UtOMPRESSED AIR formation attached?
0 BAILED 0 OTHER ❑ YES C3 NO
-11 more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well ,
ola-
meter i
FORMATION DESCRIPTION
Coal!
It
ft
WELL DEPTH
It.
DURATION
hr. min.
DRAWDOWN
ft.
YIELD
9prn.
Land
Suria
vo
St Ahs�
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE Tra/
CAPACITY GAL.
.,,PUMP INFORMATION
TYPE SIA hwici;
MAKE I
!LOEL
ii IV CAPACITY
DEPTH
VOLTAGE -130 tip
11
WELL DRILLER NAME DATE
ADDRESS P rlud-1 AAt?�, $IGMMRE
- A O)e, G S-If
PL%thAW
3/69
14
LA.B #� 7Y 7
Yorktown Medical La" rat® Inc -` - -_ - --
Date Taken: 3/14/91 Time: 10 0 Dam
321 Kear Street Date Re ' d : 3714791 Time : 2;15pm
Yorktown Heights, N. Y. 10598
Dat o�r
epted : _
�.. �C'ol'iecteff * By: = ros't
Director: Albert H. Padovani M. T. (ASCP) PO /Client #
r Referred By:
Sampling Site: Kitchen Tap
MR. RICHARD DELORENZO Angela Rd.,
2 OGDEN RD. Putnam Valley,NY.
PEEKSKILL,NY..10566- Phone (914 ) 526 -3297
L J
REPORT ON THE QUALITY OF WATER
INORGANICS (mg /L) MICROBIOLOGICAL
Alkalinity
Chloride
Copper
_ Detergents, MBAS
Hardness, Calcium
Hardness, Total
_ Iron
_ Lead
T Manganese
Mercury
Nitrogen, Ammonia
Nitrogen, Nitrate
Nitrogen, Nitrite
_ Phosphate, Total
Silver
Sodium
._ ..: -.�. Sulfate...- •... ;. _ ..
:Suif f_Cr6,
Sulfite
_ Zinc
Standard Plate Count
(CFU /1.0 mL)
Coliform & Related Organisms
Circle Method: (5 111PN P/A
Total Coliform (y
Fecal Coliform
Fecal Streptococcus
E. Coli
KEY FOR TERMINOLOGY
LT . _ . <._ = -. Le s.s Than..., . _ ,
.._G,r ..._..
NA = Not Applicable
SA = See Attachment(.$)
TNTC Too Numerous To Count
PHYSICAL MISCELLANEOUS P = Present (Positive)
N = Not Present (Negative)
_ pH (S.U.) * = Also done because To-
_ Color (Units) tal Coliform Positive
Conductance (uhms /c)
_ Odor (TON) REMARKS COMMENTS Lab Use
_ Turbidity (NTU) j
(For Lab Use)
SAMPLE TYPE:
(Check One)
Potable
Non-potable
OUTGOING:
(Check Each)
HNo
r_ HC13
H2SO4
NaOH
ZnOAc
— Na2S203
Other:
INCOMING:
(Check Each)
L GT 4 /LE 200C
GT 200C
— pH LE 2
_pH GE 12
Other:
NYS ELAP -. 10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE ( AS)� (WAS NOT) - (NA) OF A .
SATISFACTORY.SANITARY QUALITY ACCORDING TO TH YORK STA.TE.PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE.COLLECTION.
THESE RESULTS INDICATE T THE WATER SAMPLE (DID)',-(,DID NOT) (NA) MEET THE
SATISFACTORY CHEMICAA ITY STANDARDS OF THE NEW YORK STATE BL C DRINK-
ING WATER CODES, FO THE\ ARAMETERS TESTED, AT THE TIME OF SAMP COLLECTION.
7 /87(Rvsd1 /90)RVE
(ASCP) . Director
PtnW COUNTY DEPAR'.[ME TP OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
•'�i Y� /. /// ,(/ � /v /�� /y/ /yy rip•, "r' +Y.< :�...�w. R.._ nc:.. - ±ly�Sna +f 0l�•- Pv - 9� .. -.... _.-.. ..
��V�LT l/��i/ / V / �%/ I — - s -..s �.. T• �4 ^may j' ��wT�.K�tw��.
Owner or Purchaser of Building Secti6n Block Lot'
Building Constructed by
1/9 cj e-/R of-) re:
Location - Street
pu lam
Municipality
- -- -gilding Type --
/,06/ s�� 2 V
Gilbert Acres
Subdivision Name
5
Subdivision Lot #
GUARAN ME OF SUBSURFACE SEWhGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the
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 i,mnediately 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 properly is
by the; 41-11ful_-.or - negligent .:act of the occupant- .of .:.:the, building -ut lizing. _
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 utilizing
the system.
Da this day of AM- 19�
(Owner) - Signature
Corporation Name (if Corp.)
18 Angela Drive, Putnam Valley, N.Y.
Address
rev® 9/85
mk
Signature
Title
i! �l
d /
Corporation - Uf Corp.)
Address
PUnUM COMM MAZYMMM OORRAIM
- ` ✓ ® /�*i! ` Oiddin dDbriltaowhl Beef l..leo.. Cta" ILY.10V b Pr.vW lr.le t
Rev..
10/88
a• O!
i� ace UWAM O�OUL nUM Poleax • p -�
llilirlar lia YLt i Map-
- ilarA
ROWWOI PI Roddest ❑
OwR /AllieNt 1'Irp �/ C�G� ✓ G� ,117 .�.i�(✓'d"C -7Jo -�
Dalo of Ptavlwa Appwd G,
ra•N. Athena lgv 5 j��.�i�'.. flS� zoo zip
Rate Subdivision ADRr /oved f/; Fee Enclosed ® Amnnnf'
is
Oi lyp � i l LT c�i'! L`i'g� Am 7* ��1 �' � pf Seeds o* LJ Dwa-vaimm,
Mier of leitier_ - Dedpo Platy G PD �®' r? 0 POW NeffiCiijkla Y Regdmd Wises Pik is eeyleled
Sa*aabM Sweep Syatali Is aatt" d /2j �� gegide Tmk mad
To be, esmilk at 4by Adllt
Waiar !Ltr= /tq;tle SqP* Pketa AAdieea
.n y IPdv-- S 1 It anti by •a�"•�•
1 mpmmdn .that 1 am whony and completey responsible for the design and location of the proposed system(s). 1) that the ate aver di ssl stem
above described will be constructed as shown on the approved amendment thereto and M accordance with the standards, rules s r: ns
county Department of Hann. moth" on completion, thereof a ..Certificate of Construction C tisfactory to the Commissioner of Meelthwill
be subin ed to the Department, and a written guarantee will be furnished the owner, his td►� signs by the builder. that said builder will
ohm M geld .eparstMg opmdRlon. any pert of said »wale disposal system during the S lately following the "to of the how
on" of the aMroeal of the CwtowAte of Comtrudbn Compliance of the original Cyst or ) that the drilled well Ws- Mind stove
wo be located as shows so the approved p1M and that Yid we" will be Installed M accords t ru and reg s of the Putnam
County cmpee wmw of I'116
Oat• sue /3/ Signed
License No
APPROVED FOR CONSTRUCTION: This approval expires two years from the
Nraaable for cause or may be amender or modified when Considered necessary
MWIr" a permit. Apo mall for disposal of domestic sanitary sv
Oats
is been undertaken and is
alteration of Construction
?}, a �m�o�oe�ena
.� , ,-• /Yii YlYa�lvi
FUTNAArd COIINTY DEP OEr'EEE++ALTH ,
4 ' DIv181on of E�v(ronmeatal Haslet S®rvioee Carmel. N V. E05E? E�loeer to PeovWe'Pet�it p
6:. `? - , ,o® CER'E9FlCATH +.OFaCO LIANCIl �+ B
pOIW1� fl" { 'f V y
CONMUCnON N FOR SEWAGE DISPOSAL $7fSTEM
j`� z
o�an or 'VISaRe
S®bdlJ[ebn Nike �/ �� ttIA. Lot M Tcia Ellask �' Eot
Owner %Appncant Name, � . Rene�ral_❑ Revleion p
_ Date
119a01o8 Addreee � � •' ;: = _ Town t 7Ap ` % • O�� '_�
Prevbae.Approvel
Eiandlog Type Lot Area Fin Secaon only Depat Volume
Na®itei of Hedroome DeWgU Flow G P D PCHD Noa6ceaon Is goglaireid FID Is completed
l QCi
Separate Seweege Syete® to conel®t ot✓ Gallon Sep4k.Tenk ��►
To:ba+ oomteaeted t►y °4 Address
Water SuPPI)IIc Supply From Addre®e-
f F
on Private Supply DdRod by ` CO ddeeea '
Other Reoahmmente� COCA �/ /f
I represent tli6t, t am wholly and completely ►esponsitile for the design antl location of systom(s) 1) that t g, soparate, sewage disposal_syftem
abova;pestnbed -'will be constructed as shown on the.aDProvedamendment there:;tD a���aQFor �tle standards, rules.an regu,.a, Ions o e. .0 nam
County, Ospertment' of Health and that on completion theieot s Ce titivate 8tistr` "r ' e' satisfactory,to; Pn Commissioner of Haatth,will
De suDmittod „to the Department; and a writton 'guarantee''will De fu ►Wished" ew E1Adliiidb s or aligns by the builgar that said. builder will
place; m gootl operating; condition any part of faitl sewage; tlisposat syste ,auri ` �le, perbtl a, (2,). ears Immediately tollovyirg Medafe of the, issu-
w
a, of the approval of `.the Certificate,ot Construction Compliance_ ;of t ror 3`st any, ii} hereto;' that. the;tlrilled well descfibfd ;e0ove
will :located as shown o,n the approved plan and that said well wUl be in tall t t' n ►ds, ' s a u au a 1Tf', ns of `the • Putnam
County Oe rtment o Health
Oote 1i
` : Signatl P E R A
Adgreu - License No
APPROVED FOR CONST.R UCTION T s` approval ;expires two years f[om 'i a1:�sSy' • ion f the building has'been undertaken and is
revocable for .cause or m'sy De a and or modlfled.when considered.neces y,::D ea Ariy change or aneration of construction.-
, repuires anew. r —;a p v i disposal ofr.domesticaanita y.'sa e,.'. / i` I� onl
Rev. _ g$i .
1/87 Date 8Y ° Title
F�
23
l
• j.
IL, S7
lzv
CR
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b_ F= 1 11 sc-c—Litcn - Dam cf piac-r =llt
i I I
brush- ECC_ C"_C ='" Lm=-', 1 f=C-iu S:.0 Ems_ I I I
E_ 1010 ft- f_c tea__
D crc t I I I
a_
se- tic tank s. == - 1,000 1.250
='n _:1 10 Cf 45:3
Prci=r�— C:eC! : f = ^.L
-�= - _- r= =i `Ci i _ ar cc
EN=EMN E;77
inS
/32 0/=Cci._
C- - . r -_ .c r-- l -- -
C_ l Q yam_ C. �, L�J -
7.
D- c= < 30
6. RCC =11 c ! = .-Cr ex =icr, 50%
I J _ r, rte-! C= C= "7� 2= t _. mc-- 12" Ruz- —.:-m
11. p,E =c
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E. C`r c w_--= =_- be Ec i L:- Denaztmazt
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C_ C = =_%:C 18ff c_:'�c CCcr c
c_ ,- -Xas crCC= =_'i C =CL•
c- A.!--- L-i=es flu�n With inside of 1:,--x
C_ i - =1r_i 11 Ii. = = -'a CCI:�?il_c SLC• ^ES < 4" in ri =•:=r_
_'S7 ac crdi_^_C LO
C-=-- i -TL` CAL= =! L'r'Cta `=
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P ..
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APP'' ICA-T1ON _ -TO- --CONS UC T' -�A 11ATE�
PCHD PERMIT
WELL LOCATION
Street Address Town/Village/City Tax, Grid Number_
WELL OWNER
NamV
Mailing Address j )gPrivate
eX_51 /I N O Public
USE OF WELL
-1 - primary.
2 - secondary
RESIDENTIAL
0 BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
' gpm /# PFOPLE SERVED .4 /EST. OF DAILY USAGE gO& gal
REASON FOR
DRILLING
XNEW SUPPLY (:)PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN ODUG
®GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Y NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. S
WATER WELL CONTRACTOR: Name A • Az7 �S p'1r7 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES � NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO -PROPERT`Z -FROM NEAREST WATER 14AIN': _
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION []ON SEPARATE SHEET i
(date)
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 s.hall:
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 Department.
Date of Issue: /=z°� 19
Date of Expiration: jr 19 Permit Issuing cia
Permit is Non - Transferrable White copy: H.D. File
Ye11oW Copy: Btuldi.ng InsPENctor
Pink Copy: Owner
287 Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
.-- ::APPLT -CAT —0N; TO=
PCHD PERMIT
WELL LOCATION
Street Addrg&s To Village /Cit Tax Grid Number
n alq rJ#-e �
WELL OWNER
N e ailing
Address
X .6F Ln v /r
rivate
O Public
USE OF WELL
1 - primary
2- secondary
[SIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT P
O BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL O INSTITUTIONAL . O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
PEOPLE SERVED_ /EST. OF DAILY USAGE, gal
REASON FOR
DRILLING
SUPPLY
O REPLACE EXISTING SUPPLY
OPROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
RILLED
DRIVEN
QDUG
®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ,� NO
IF WELL IS LOCATED IN A REALTY SUBD VISI N NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Ay &V2;y/j Address : �r /�<� � ✓e
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
. ,iISTANCE'TO PROPERTY -FROM- -NEAREST- -WATER - MAIN - :; ... • .._ ..m, r:= .., v �.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
/
[]ON REAR OF THIS APPLICATION Q ON SEPARATE SHEET
(date) 4 i re
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 s.hall:
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 P nam Co t
Health Department./
Date of Issue: -24 19
Date of Expiration: 19 er t Issuing fficia
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
a
N u � -'VLLi ti
' PTUIN71 - -M Crb -L\n -' D =AFMI� -?r OF EE.'=a - D- r7ISICN CF r.VG —i Cr &—E-ITD.L DI=IH S -N7T�S
DIDIVIZCT. L WAI=R SUPPLY & Su'z,j- tF:'-C✓ DISFCs�z Sls=T -
REV—rP *N „rc' = -?' - CGNSI='`ICN PS- M-!T L 3
D_1A REc 7, F
p
-7` .r- -
�Sf �� '.. .l_ 1 •.+..} C' �K. _ - - yr ♦ .. . ..... r . .. ��� . .. 'r�T� � �l �.... -._ '•�r _. -•vr l .
Mane of C•NT:ar)
Cam' 4L IS I ` I m ( DCC'y'�irs
1
Permu - Appiication O �,�--
Corper to Rescluticn vCJ
Plans - Thr'ee s`ts '
Fmcinc -- -s A_uthcrizatica
Des ice Data �liE✓_ ( G� )
Duo aoic L.^c
s;
CCnsis an= Pe'_"C Re-c -- i t ( 3
I I I Pe_Tc Hole Gepth
i I _
I fic•,:�_
Plans Two set
We11
vzr _a r=
I I I S�.iT�i-r sicn AJor'cva_ C___s= -
L
i
O
-
3 0-
60 t.
b
100 °' e;• � .
I.
�v v
I
7:14 S'ST�S
C. 'rCz -- - `r
L—IA not °_s
..=. sec.
11'0 F'' CCd ei.v. i /I I
1
Ex -a: rctia- S-SLS
K :..`. Cii Ocs plans Gels & P e = -. _ •.G..-
uL�� DFT-Ti , C CN P� =�
SU�E1V1c C�.; ..
PcrC ¢ rQ
F• c
i
c-
Fill Prof.-Lima &
peptic Ta.,!:C - Si , Cet�il
well CeT =_1, Servics L _._ i= c:
Crnst� cti cn
Notes (crinGer �t�)
Cesicn Data: ie'_ c.ic.�Ceeo rcs,_-_.
T c = out Cant- ur = maxis " i -n & c- ��;cs
- Dri�rYa & S`i cc�s "C'atr ::..._ -_ .....
Fc0LL I C�G:,ri. r,C.irtt? ;r, Or inss (al-isc''_Srge
Perc & Deep moles
Repre_=z�-mta.tive or prim`Y� ex- nansica
Ec. nsicn AT_;shcH-re t'T
I= PP zm=^: Pit & D Eox Si:cv -n & C *-�. i 1
Rouse - No. Cf Eedsccn=.
Wells & SEDS' w/-in 200 ft. . c, r cocsaa 5�=t=
Prccer�,'T Metes & Ecurd=
-HCuse Cct:cC:{ Necassar (`T'icha 1ct)
House ever - 1/4"/ft- -d„
No - M=-c- Bends 45° w /c- e:--rcut
SFrD-,':-P-UICN DISZ -N =7 SZ —T = CN Pr._y
Field--
10' to P.L., Drive.iav, T_aes,TC_ of _
20' to Fcurc =ticn We? 1s
100' to Well; 200' in D.L.O.D, 150' pit=
100' to Stream , Wct rcour = =e, TEaka ('=iC. e:,-_.
15' to in, L,---C.2_', FCoLl!1C
35'ta CtC Sin, stC�C ? n, C1 we - =T:
10' to Rater Line (pit = -20')
50' inta*--ti t tent dr_ir_ce c`�-sa
S-2oti c T.r.K=.
10' f= F zunc,ticn; 50' to :vaI1
L' we-Ii to PL
PUTNAM COUNTY DEPARTMENT OF
DIVISION OF •• •' b M Y' HEALTH SERVICES
DESIGN DATA SHE T- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner ° ✓C Address /�� I� y- Y�i��air /�ai��1
Located at ( Street) P/ # Sec. 1,9 Block a, Lot 2-2-
(indi e nearest cross street)
Municipaiity �//X
Watershed
Date of Pre - Soaking &1) Date of Percolation Test
HOLE
NUMBER CI= TIME PERCOLATION 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
1 41.2- O-3 P" a! 2-2- z S-
2
3 15--
4
4
5
1
2
3
4
1. Tests to be repeated
are obtained at each
for review.
2 -. Depth measurements to
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made fran top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO HOLE NO. Z HOLE NO.
rs ..- e.�_ -..a �•»a... c� _ __ �. . a.-�'m1.r�. s..... -.KS.. s.-. .:i -r.i .._ -..pm• . y �t�.. 'e4,..
p... .aa�e . -�:• - a ,c>t,O...: s:��.n -r4a. �,c- - - � •.e +.�'.-
G L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDRATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: /e ��/ ✓A!% DATE:
DESIGN
Soil Rate Used /U Min /1" Drop: S.D. Usable Area Provided doa U
No. of Bedrooms Septic Tank Capacity %% gals. Type
Absorption Area Provided By
L.F. x 24" width
trench
Other
SMn N;
a M 1
Name d / d�C Si6n3b� r
Address
THIS SPACE FOR USE BY
Soil Rate Approved
DEPARDEM ONLY:
sq <ftfejal.
Checked by Date
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