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HomeMy WebLinkAbout4285DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.83 -1 -22 BOX 32 04285 � J i .� �� s .L T a *a 9 04285 ev. 3/ Located PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 Engineer Mast Provide J !� - P.C.H.D. Permit q OF CONSTRUCTION.COMPLLANCE FOR -SE! y� ®�� ��/ sy Owner /alpptt�nt Name Formerly Mailing Address �O �2.5 Zip Separate Sewerage System built by O S Add Consisting of '49 G G Gallon Septic Tank and Town or Village Tax Map "E :3 Block 1 , Lot Subdivision Name -' FR Subdv. Lot q ' Date Permit issued L Water Supply: Public Supply From Address or: Private Supply Drilled by , Address �y Z;VeY- Building Type �i 5 / G" f r Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? �d Other Requirements I certify that the system(s) as listed serving the above premises were constructed essenti caH"sho on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulations, in hilt' filed plan, and the permit issued by the Putnam County Department Of Health. y / Date Certif ad by P.E. R.A. Address Licence No.>'�yJ 5 Any person occupying premises served by the abor✓ ystem(s) shall promptly take such action as may be Itei s}%i6 acure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage em shall become null and voi as soon as a Pubt% unitary awer becomes available and the approval of the private water supply shall become null d v kt when a public water °_. supply -;tiecomes available. Such approvals are subject tom ifi �iionn or change when, In the judgment of the Co s o r of Healt ch revoeatktn; if otllflcatIon or change Is necessary. Date L Yg ° 8Y Title _LSL.1& PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Heath Servleea. Cannel, N.Y. 10512 Engineer to Provide Permit q NS'TIS6JLnQlIR1.P�I IRtr e2iB sEwA€ T; s�^±9 Y% �YSTM Located at G'o O/'f ° Q Subdivision Name A L ow�r /AppllcantName /S'y�s7 /� /a�� �j MaWog Address / o %�c. -' e . �t' -d /Y�j w,: , on CERTIFICATE OF CO CE Town or Village Tax Map 120 Block *2- Lot Renewal_ ❑ Revision ❑ Date of Previous Approval Town ZIP Building Type //mil / Lot Area J"G'- Fm Secdon Only Depth Volume Number of Bedrooms �. Design Flow G P D �pU PCHD Notillendon is Required When Is completed Separate Sewerage System to IfjOCd Gallon Sep* Tank and 2 2 ;24'l yY3 1i C ds To be constructed by Address Water SuPPb': Public Supply From Address or: rf Private Supply Drilled by Addr fts Other Requirements I represditt that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance ards, rules an regulations o e Putnam County Department of Health, and that on completion thereof a "Certificate of Construction ptjS:Qi�'N i cry to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his by the builder, that said builder will place in good. operating condition any part of said sewage disposal system during the per o ��s dl ately following thatlats of the issu- ance of the ipproval of the Certificate of Construction Compliance of the original syste or re er fA 2) t the drilled well described above will be located as shown on the approved plan and that said well will be installed In accords It St r s,. as d regu a�f the Putnam County Oepa/ ent of Health s , Date i Signed P.E. _ R.A. Address �y ^ �� License No APPROVED FOR CONSTRUCTION: T is approval' expires two years from the a issued unl I S fl uilding has been undertaken and is revocable for cause or may be amen or modified when considered necessary by the Commiss( O M161 46, change or alteration of construction reCuires a new peyymit. P,pprov for disposal of domesti sa y sewage, an or private water APPrtpVQp f+pR Cp{ ' f®e0i001k1ONa0Ulia®P "OWL," a 'aaa,. maims a of too 0uildit has Dow uwdaitakon apd 1s ik. Awy charge et or alteration of tonvuet*n _- WLIjL L/Vr1CLL .L 1VLN REFOR1 DEPARTMENT OF HEALTH - .. - - -D.ivisiorL Of. -.Ent ironmental Health, Ser - ices_„ .— -- ^ W Y PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only WELL LOCATION STREET AOURESS: WN /vll / 1 Y TAX GRID NUMBER: WELL OWNER NAME: ADDRESS: f: 1• 4e is /( !- ��liaw R '�fh��, �% //� B"P9IVATE ❑.PUBLIC USE OF WELL 1'- primary 2 - secondary ©/RESIDENTIAL O PUBLIC SUPPLY ❑ AIR/ CONDJHEAT PUMP ❑ ABANDON D O BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED I EST. OF DAILY USAGE gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY ffjI4EW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH. ft: STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT 8/ROTARY O COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O'OPEN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH S tL - MATERIALS- 0 --TEEL O PLASTIC ❑ OTHER LENGTH BELOW GRADE a•s� ft. JOINTS: O WELDED CYTHREADED ❑ OTHER DIAMETER in. SEAL: O CEMENT GROUT ❑ BENTONITE ❑'OTHER WEIGHT PER FOOT lb./It. I DRIVE SHOE: ❑ YES C] NO LINER: ❑ YES Q'1V0 SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO SECOND GRAVEL PACK ❑ NO SIZE: GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM OEM It. WELL YIELD TEST If detailed pumping METHOD: O PUMPED ; tests were done is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER ❑ YES 0 NO t �IELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Rear- inn well Oia- In FORMATION OESCAIPTION tDOE tt tt WELL DEPTH ft. DURATION hr, min. DRAWOOWN it, YIELD gpm. Surface WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME GATE _ ADDRESS r%Yrh�. J' stGfrkTURE / 6v I ) 1 I d PUTNAM COUNTY DEPARTMENT OF HEALTH o ....... ...__........_ _ aWITROMMAri - - Ail, Owner or Purchaser of Building // Building Constructed by Location - Street Municipality Building Type ? -L Section Block Lot Subdivision Name Subdivision Lot # GUARANM OF SUBSURFACE SEWAGE 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 fora period of two years _imnediately following the date of approval of the ,. -.-,. ��..��e�t�fie- ate•- o�= G�s��etion.:.Cor;,p =iane�" - fern = the :` -e- wage•- �'a:s�sa?�:s�s -o�- and' -y- . 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 Environinental 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 _ day of l&' c" 19 Gen al Contractor (owner) - Signature Corporatio Name (if Corp.) i 4,/�VIW / /fW AACI rev. 9/85 mk Signature Title Corporation Name (if Corp.) Address DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLION TO CONSTRUCTYA WATER WE LL CATI PCHD PERMIT # WELL LOCATION „_,S reet Address .� Town/Village/City Tax Grid Number ✓� �,� L r- WELL OWNER ame Mailing Address S/ - Private U '5�� /dpyL / 'V'_ c' � � ��/77� /�t O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT 4W O ABANDONED 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify O INDUSTRIAL U INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT � gpm /# PEOPLE SERVED .- /EST. OF DAILY USAGE h gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLINGI ❑ TEST /OBSERVATION 11. ADDITIONAL SUPPLY 13 DEEPEN E2JISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED 13DRIVEN ODUG GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION df c, Lot No. WATER WELL CONTRACTOR: Name �e Address: /` y" IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES a NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY -- - DISTANCE' TO_'PROPERTY _FROM NEA.REST=:WA ER=MAIN: - - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE ,OON SEPARATE SHEET (d te) (signature) 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 shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller �i4R­ V,W OVELL Inspector i TOWN OF PUTNAM VALLEY BUILDING, ZONING, AND SANITARY DEPARTMENT December 271 1988 Dept. of Health 110 Old Route 6 Carmel, N.Y. 10512 TOWN HALL -:0 iff NA*1 *A t--ifY (914) 526 2377 Re: SSDS Repair or Expansion TM#PV le) g - 2 2-7 Owner: �Qosae t Dear Sir or Madam: The proposed alteration of Sewage Disposal System as shown on drawings dated 17,6-4k have been reviewed and determined to be in compliance with 1. Wetland regulations. 2. Information on file in Building Department. 3. Separation to adjacent water supplies. Applicants that receive permits shall advise the Putnam Valley Building Department when construction is to -c same. An "As Built" drawing of said work shall be submitted to the Putnam Valley Building Inspectors office upon completion of work: Building ­_P2oning Inspector DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 I�;; 7 --�, . PCHD PERMIT 4 P�'��7 WELL LOCATION Street Address TownyV�il age City Tax Grid Mbr WELL OWNER yFamQ --�— ilin Address rivate j m t-►��° mac/ G,�y'�j O Public USE OF WELL 1 - primary 2- secondary U ESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, p AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING EW SUPPLY O REPLACE EXISTING O PROVIDE ADDITIONAL SUPPLY SUPPLY O DEEPEN EXISTING WELL (3 TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE V315RILLED ODRIVEN E]DUG ®GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES A--� NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name h ✓yw Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: .YES NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DSTATGE =TO:�ROPERTY. FROM �TEe�RF,S7. WATER MAIN' :. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION OON SEPARATE SHE 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 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 provided by the Putnam County \ Health Department. of Issue: ��� �� 19 �� 11 ti � f Expiration:;_r%f� -✓ 'lo 19 �� ermit ssuiXile fficia Non- Transferrable White copy: H. Yellow copy: Building Inspector. Pink Copy: Owner orange copy: Well Driller r 4 r DESIGN DATA SHEET- SUBSUFACE' SEWAGE DISPOS� - ` t �NO. owner JHrKOWSK10 Afce-Fy Address ,'--- Located at (Street) Sec. Block Lot (indicate neare t /cross street) Muliicipality _... Watershed - -• ■ ' �1a�• : ii �;� Y i � � Y. ; �� )I•. �• \�jC�� -1 1:M YYY��.1fY�: : • ' ■I_ Y ■;► � Date of Pre- Soaking Date of Percolation Test HOLE NUDBER CL= TII PERCOLATION PERCOLATION RM Elapse Depth to Water Frcm Water Level Fp, Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In min/in Drop Inches Inches Inches N w J ;� _ 2 /0 ', O "ISS 7 3 to 4 2 3 4 5 hCE #3 1 2 3 4 5 IM: 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. 5 2 3 4 5 hCE #3 1 2 3 4 5 IM: 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. A 2P=, I:C B PUDI M CCM -TrZ DEP .FM= OF b-EnTH - DIVISIO OF 24=C�ZfETML H a=,,ri S-an4 ICES LIDITiM UAL W-A= SuP°LZ & SU-ES UFFA=- SZy� DISiI.,S.AL SYSTEMS TT DATE, R,c -T, =. ; . A.,1 ?A t (Name of Cwnar -) (Street Lccaticn DCC'2!Rfl'S Permit R.ppl i cation COr�:cratS Resclut' -cn Plans - Three sits S/s Fmcinears Pait_-icr_zeticn Dct--- SIie✓-t UD -) S ^�Drr�IC�r Deep Hci! s Lcc parc Ccr-E6Ste-it Perc Re_-,, is Perc sole Derot:i cz . Hct:se P.1- s – r c S=am_ Well F;.1S Variance Remuest �—RAL Su'r,-H�rsicn Acc 6-Va7 C_ecc�f F:x = once_ SSCS Ad-:. L`t_ We _d (Tc�� /DEC Pe__::? = R & D ) Dc tr C-a DGS Plans & P°__ mi t Sams DE,-- =,, C-N Sewage S?st`m Plar. arrow) S�.vccc SySt_T nyC� =t-71C P_O___� - r_.=-.:_f r,C Fill i Prof;- e lII:ens? cns D cr S�ctit'Tank - Size, Mail Well DeT -T1, Ser-f1cs U7.1e i _ G:ns`~icticn Hates cr_ncer r t =) TI c-Fcct Contours ^xi s:.i nc & P_cccs Drivavav & .Sloces Cat FcoLin /Gat =er,L`.:i- ,..a?:. Drains (cic.±iE-:rce CK) Perc & Deeo Holes Located Representative or prim -rl and `{- ansicn RKpansica P.ra-; show -n; -ravit,,r f1c07, s-sfi: Size If Pmce5 Pit & D Bcx Shcwm & De+-- iled Hcuse a No. Of Bedroans Weds s &,SECS Is w/-in 200 ft. of P- -Cccsed Svst- *Me4 - =s & -i cu :ds Ecuse S&-back Necessar ti (T'icht lct) Hcuse Sever - 1 /4 " /ft. a "O; r`rTOe page NO ^^s; {. Bends- 43' w /c_eancut SE ARATICU DISTriN== SPE'CT77M CN PT-rN Fields 10' to P.L., DriVcjvaIT, Is J e Ti= e --,Tcc Of L 20' to Founc?aticn Wails _ 100' to Well; 200' In D.L.O.D, 1f0' P1 -m 100' to Stream, Wat_rcoursa, -T- (inc. (inc. er 15' to Drains --= =in, L�dar, Fcctinc 35 "tc C..''tC'1 We taro.^_ is 10' to '►Galen Line 50' int =r-1 ttent drain =.ce cc "r Sectic Tanks 10' f_cn Fcunc_ticn; 50' to well 0 15' Lvzl to PL ' YES I NO i I I I I i i I I I I �t I sJ�- oCr i I NJ V 3b 6 ra -_= S66 �� 60 ft. r-La:{. Fa~ _l to contours G 100% I I I I I I I I I I I I i I 1 I I I F= SY5 � 1 clay = e_r I - I 10 f= . f V notes I I r_ . s —. I I _otn Cauce_ I �I I I "114 1 1,120 vr. f?ccd elev. 200 ft. reservoir, etc. I 1 =J ft_ I I QII DCC'2!Rfl'S Permit R.ppl i cation COr�:cratS Resclut' -cn Plans - Three sits S/s Fmcinears Pait_-icr_zeticn Dct--- SIie✓-t UD -) S ^�Drr�IC�r Deep Hci! s Lcc parc Ccr-E6Ste-it Perc Re_-,, is Perc sole Derot:i cz . Hct:se P.1- s – r c S=am_ Well F;.1S Variance Remuest �—RAL Su'r,-H�rsicn Acc 6-Va7 C_ecc�f F:x = once_ SSCS Ad-:. L`t_ We _d (Tc�� /DEC Pe__::? = R & D ) Dc tr C-a DGS Plans & P°__ mi t Sams DE,-- =,, C-N Sewage S?st`m Plar. arrow) S�.vccc SySt_T nyC� =t-71C P_O___� - r_.=-.:_f r,C Fill i Prof;- e lII:ens? cns D cr S�ctit'Tank - Size, Mail Well DeT -T1, Ser-f1cs U7.1e i _ G:ns`~icticn Hates cr_ncer r t =) TI c-Fcct Contours ^xi s:.i nc & P_cccs Drivavav & .Sloces Cat FcoLin /Gat =er,L`.:i- ,..a?:. Drains (cic.±iE-:rce CK) Perc & Deeo Holes Located Representative or prim -rl and `{- ansicn RKpansica P.ra-; show -n; -ravit,,r f1c07, s-sfi: Size If Pmce5 Pit & D Bcx Shcwm & De+-- iled Hcuse a No. Of Bedroans Weds s &,SECS Is w/-in 200 ft. of P- -Cccsed Svst- *Me4 - =s & -i cu :ds Ecuse S&-back Necessar ti (T'icht lct) Hcuse Sever - 1 /4 " /ft. a "O; r`rTOe page NO ^^s; {. Bends- 43' w /c_eancut SE ARATICU DISTriN== SPE'CT77M CN PT-rN Fields 10' to P.L., DriVcjvaIT, Is J e Ti= e --,Tcc Of L 20' to Founc?aticn Wails _ 100' to Well; 200' In D.L.O.D, 1f0' P1 -m 100' to Stream, Wat_rcoursa, -T- (inc. (inc. er 15' to Drains --= =in, L�dar, Fcctinc 35 "tc C..''tC'1 We taro.^_ is 10' to '►Galen Line 50' int =r-1 ttent drain =.ce cc "r Sectic Tanks 10' f_cn Fcunc_ticn; 50' to well 0 15' Lvzl to PL ' I z 0 VA 0) al Q'I *14 ty, 12, due) 45. .10, WW Louie M DISPOSAL SYSTEM FILE. bl). X Y1, Address O ,� wner Located at (Street) 1��,VZyz- zA fq/ Sec. 2q Block Lot (indicate nearest. oss street) Municipality /V/ Watershed SOIL PERCOLATION TEST DATA REOunm M BE SUBMITTED WITH APPLICATIONS Date of Pre-Soaking Date of Percolation Test HOLE NUMBER CLOCK TIME PERC2LATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In YAin/In Drop Inches Inches Inches ;175 4 5 a __ 4 5 2 3 4 5 NOTES: 1. Tests to be repeated* at saw depth until approximately equal soil rates are obtainedat each percolation test hole.. All data to'be suhrdtted for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEP_ TH. HOLE NO. ._�.. /' HOLE •NO. 'i'.i_i "' _ � %�J+_._ _.. ��id'J.� .. - .. _ .. - _. �'il...b'..""`w.00'� LY• -.�t� "'s ...T'.`. �._- •1��'. ... ,V�J' . G.L. 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH �GROUNDWATER, IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: l/ / y -4;101 DATE :�/ DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity �Gi1 gals. Type /�t�11�•�' Absorption Area Provided By ? C/ 62 L.F. x 24" width.,trench Other /- Name Address i9 FOR USE BY HEALTH DEPAMENP ONLY: Soil Rate Approved sq.ft /gal. t 4 OF Neo Ina YP s ROFe5510N Py Checked by Date