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BOX 34
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NJ
04512
ENGINEER MUST ,
PUTNAM COUNTY DEPARTMENT OF HEALTH PROVIDE r
J (, Division of Environmental Health Services, Carmel, N. Y. 10512 PERMIT #
CERTIFICATE 9CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM �y W
.. i�j:: rs"`= :'%a,�+?..:P:'%:pa ~:,y.+e ...•.t 1 :. ".:.. 7- �ria� .�u`:.�y':r- w•�. ":irT.�..:: o::'�,ti.,;...: - =� <, .w' :t .1.. ...� �.,. �._-. .. c. , 'f+-AI
. 11 'e✓il, /s .. Taxi s �• Y`Block
Located at G
Owner �d !7'1 e: Ill Formerly Tax Map Lot ii Subd. Lot f
Separate Sewerage System built by - - Address
Consisting of U Gal. Septic Tank and
Other requirements
Water Supply:
Public Supply From —
Private Supply Drilled By
dress<
Building Type
Has Erosion Control Been Completed?
Has garbage grinder been installed? All '
I certify that the systems) as listed serving the above premises were constructed ess
own on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations
o AG
the filed plan, and the permit issued by the
Putnam County Department Of Health. ,4P
Rjr,
AN
S"
Date erti ed by
P.E. R.A.
y
Address "system(s)
License Nos
Any person occupying premises served by the ohall promptly take ch to slhece
conditions resulting from such usage. AID of the separate sewerage system cotes null a v
[lt secure the correction of any unsanitary
4 n as a public unitary sewer becomes
available and the approval of the private water supply shall become n 1 and void
�c
comes available. Such approvals are
subject to modification or change when, in the judgment of the missio or of
t
odlfication or change Is necessary.
Date to By
SSIG X%
Rev. 6/85 j
k\ _ 017 ' HEALTH eer to Provide Permit N a
1' PUTNAM CO oUN Health Sor C�+el. N.Y. 10511 on CERTIFICATE ')Pro
��\ Divleton of Envire permit 0
Rev. 3/86n
- - tvST(tlji TiGN PER+XT FOR SF
E DISPOSAL SYSTEM ` Tavrds_9r- �Be - �el
`�'
Located at U� Tax Map f— BlO� � —
�►' __Sabel. Lot N Revision ❑
Subdivision Name Renewal_.❑----- -
Date of previous Ap royal �I���p O
Owner /Applicant Name f 4."
1. MatllnB Address / f � /J /S/ %�!/ Town
�• �/ 7 ff?CE;[D NOW nly
ii� Lot Area
Buildi ng Type Design Flow G /P /D _-- O v /
N her of Bedrooms d �4
um 6�'® tic Tank any ----
Gallon Sep
Separate Sewerage System to consist of Address
To be constructed by Address —
Wate— r= pll�bllc Supply From Address
or.
private Supply Drilled by
dl
Other Requirements responsible for the design and location of the P1
roved amendment there to and in acc'
1 represent that 1 am wholly and completely
above described will be constructed as shown on the app
County Department of Health, and that on completion thereof a "Certificate of Construe
part of said sewage disposal system during A
be submitted to the Department, and a written guarantee will be furnished the ow
P in good operating condition anY Pa
anco of the approval of the Certificate of Construction Compliance of the origins will be located as shown on the approved Dlan and that said well will be installed in acc
County Dep rtment o Health. Signed
Date a
Address ate issued
rove the Cot
n co s de!pijr a`1 riv
APPROVED FOR CONSTRUCTION: This aP,Pt.T *eOdIiKN�Lh(�a1� sder r
revocable for cause or may be eddfif disposa,'D* p ° ^' � P <
squires a tiew permit. ApP
Depth — Volume - —
tegaired When Fill Is complete
the separate ---
u nom
ules an regu a tons o e
to the Commissioner of Healthwill
the builder, that said builder will
die iy following thodate Of the iSSu-
#h the drilled well described above
at$, regu a ,ons of the . Putnam
it t
P.E.– R.A. �--
License No
wilding has been undertaken and is
change or alterati�onofs�onstruction
Title ��
PUINAM COUN'i'y DEPART OF HEALTH
DIVISION OF ENVIRODZ I, HEALTH SERVICES
..= :•::;hr't-"., rk _ - ".� :3._ _ r.Fi. • -a ,— _— ��;ti:. _` :TF- .,';..° - _ __ _i__...
�7 / / �/JlI'�^4 by -{
Owner or Purchaser of Building Section Block Lot
Building Constructed by
Location — Street Subdivision Name
Municipality Subdivision Lot #
Building Type
GUARANTEE 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 for a period of two year immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any...,.,
,
z.. repa xs..made_hy.. e f^ ,,Gib.. �ysi ice' _.wh g -- 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 detetm; ration 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 uti izing
the system.
FFI
Dated this F1 A11C; h - day of L-/
Signature
rev. 9/85
mk
Le
M- M!®
4
(if Co dp. )
SCO ctajau [).Q.
ItPTWow tj N-f�. A),
10 SIC/ Y
i
a
I
WELL LOCATION
WELL OWNER
USE OF WELL
1 - primary .
2 - secondary
MOUNT OF USE
REASON FOR
DRILLING
DEPTH DATA
DRILLING
EQUIPMENT
WELL TYPE
CASING
DETAILS
SCREEN
DFTAILS
....
x - -�
WELL COMPLETION REPORT Office Use Only
DEPARTMENT OF.HEALTR
Division.Of.Environmental Health Services
-cs a r. - . - _. ��-� � �+:p - ;•;,'°'�.:.a::. .��� .. �_� y.�:r . '3:.�� .>. ... -
PUTNAM COUNTY DEPARTMENT OF HEALTH
TAX GRIO NUMBER:
I)W PRIVATE
O PUBLIC
10 RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED
• BUSINESS O. FARM O TEST /OBSERVATION ❑ OTHER (specify)
• INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
YIELD SOUGHT �� gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL DEPTH, /71" ft. STATIC WATER LEVEL ft. DATE MEASURED
* ROTARY . ❑ CQMPR ED AIR P CUSSION G� DG
O WELL POINT 0,CA8LE 1ERCUS5t TH R (specify):
O SCREENED ❑ OPEN
END >.CASIN;
E3 OPEN HF IN BEDROCK
O OTHER
TOTAL LENGTH
; formation attached?
ft
MATERIALS: ,&STEEL ❑ PLASTIC O OTHER
LENGTH.BELOW GRADE
DIAMETER
ft.
JOINTS: 0-WELDED S_THREADED ❑ OTHER
DIAMETER
G'i
i� `
SEAL: ❑ CEMENT GROUT O,.R , PM, E WTHER
WEIGHT
PER FOOT
�— Ib.lft:
DRIVESH i Y- O NO
'INEA:OYES. SLNO
DIAMETER (in)
'SLOT _SIZE
LENGTH
(ft)
Q.;SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
GRAVEL PACK ° YES
❑ NO
WELL YIELU TEST
If detailed pumping
METHOD: O PUMPED
t tests were done is in-
O- OMPRESSED AIR
; formation attached?
O BAILED O OTHER
GRAVEL
WELL DEPTH
DIAMETER
DRAWOOWN
TOP
ft.
BOTT061
SIZE
gpm.
OF PACK
in.
DEPTH
tL
DEPTH _
WELL YIELU TEST
If detailed pumping
METHOD: O PUMPED
t tests were done is in-
O- OMPRESSED AIR
; formation attached?
O BAILED O OTHER
; Cl YES O NO
WELL DEPTH
I DURATION
DRAWOOWN
YIELD
ft.
hr. min.
ft
gpm.
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH 3
r
MODEL I Lok" VOLTAGE7130 HP 3
WELL LOG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM water Well
SURFACE sear- Dia- FORMATION DESCRIPTION
ft. I ft. ing meter
;and / r /_ v /I 7
a
CODE.
STORAGE TANK: TYPE
CAPACITY 0�%0
WELL DRILLER NAME
GAL.
32.012247
Yorktown Medical Laboratory, Inc. LAB # -- --
321 Kear Street SZ'
Date. y
Time
Time:
(914) 245 -3203 Date Reported: 1$68
Director: Albert H. Padovani M. T. (ASCP) Collected By • J-4 • ,ie�✓ %iss?a /�ZU
T_ -1 Referred By:
� �L•'7n1 / 0 � /�,�ZL�7iJ Sample Location: %r, /-
Phone N
Phone # Sample Type:
Repeat Test? (check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
Standard Plate
(Agar Plate
Count (CFU /1.OmL)
@ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
1zTotal Coliform (CFU /100mL)
Fecal Coliform (CFU /100mL)
Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
Tota1...Col.i,form. MPN_In_cje_xp_( er 100mL)
Fecal Coliform: MPN Index (per 100mL)
t it
WM
V%Potable
Non- potable
STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
— Na2S203
Incoming.
4ZLE 4 °C
GT 4 °C
OTHER ANALYSES KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of Source
TNTC= Too Numerous To Count
REMARKS (For Laboratory Use) CON '= Confluent ( =TNTC)
LE = Less.Than or Equal to
GT = Greater Than.
N/A = Not Applicable
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE N YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
t' _
Albert H. Padovani, M.T...(ASCP), Director
For Lab Use Only:
_ H/C to
FINAL SITE INSPECTION Date
` S LOCATION Rw fm- - C 1 Z G/ Inspected by C. �'r � �''� OWNER ( "I G�Ni
PERMIT # .0 ~V"'�� / �( �, TM # OR SUBDIVISION LOT #
'I.
a
II<
IV.
V.
R
►�lJYYt'��1� lll►7iVJL"iLl• cYara � =jr i _ - "r- ��a"^' -- � _-`5`.
a. SDS area located as per approved plans
-�� -
b. Fill section - Date of placement
2:1 barrier_ LGTH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 15' fran SDS area.
e. 100 ft. fran water course /wetlands.
SEZ%GE DISPOSAL SYSTEM
a. Septic tank size 1,000 1,250
,X
b. Septic tank install el
I
c. 10' minimum fran foundation
X
d. No 90° bends, cleanout within 10 ft. of 45° bend
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
3. Minimum 2 ft. original soil between box and trenches
f. JUNCTION BOX - properly set
-
g. TES
1. Length requi red - 1,200 0 Len installed 'j 0 3
2. Distance to watercourse measured, ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet fran property line - 20 feet - foundations
7. Depth of trench < 30 inches from surface
8. Ram allowed for expansion, 50%
9. Size of gravel 3/4 - 17" diameter
10. Depth of gravel in trench -12" minimum
+�G� L✓J
11. - Pipe ends ca
2
o . P-j
h. PUMP OR DOSE SYSTEMS
1. Size of p;p .;chard-)-,x
-2. OvErflow tank
3. Alarm, visual /audio
4. Pmp easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Department
estimated flaw cycle
HOUSE
a. House located per approved plans.
b. Number of bedrooms
WESsI, -
a. Well located as per a roved plans
b. Distance from SDS area measured (, ft.
c. Casing 18" above grade.
d.- Surface drainage around well acceptable.
OVERALL WORKMASHIP -
a. Boxes properly grouted
X
b. All pipes partially backfilled
c. All pipes flush with inside of box
d. Backf ill material contains stones < 4" in diameter
e. Curtain drain installed according_ to plan
,e
f. Curtain drain outfall protected & dir.to exist.watercours
g. Footing drains discharge away fran SDS area
h. Surface water protection adecRmte
}(,
i. Errosi.on control provided on slopes greater than 15 %.
10
utr^K i MtN i Ur HtAL I H
= Division Of Environmental Huh Services
TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641 _
,..:z ........ --
CATuN: TOCCNHiR ER�WEIAPPL 3I
WELL LOCATION
c I AODRESS.
►0WNiV1LLAGE 1GI1T —_ - IAX GAio NUM6EA.
/
WELL OWNER
NAME..
j'a --ew
AOORESS:
�� , �er�?��s�:y /�� .�zr =;-. �rc f'
SIVATC
p 2USLIC
USE OF -WELL
0 EESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANOONE
1 -primary
❑ BUSINESS
❑FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
2 -secondary
❑ INDUSTRIAL"
❑ INSTITUTIONAL ❑ STANO -BY
MOUNT OF-USE
YIELD SOUGHT
_ gpm. /NO. PEOPLE SERVED __— / EST. OF DAILY USAGE; gal.
REASON FOR
SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
_EW
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE I
U3 'DRILLED
a DRIVEN DUG GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? _ YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: a
LOT NO_:
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC•WATER SUPPLY: TOPo�T /V /G
DISTANCE TO PROPERTY FROM NEAREST WATER. .MA19,, .
~.LOCATION - SKETCH & SOURCES OF CONTAMINATION;
/(date) 1 (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 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:. 12266S 19__T
Permit..is .Non - Transferrable ..
• Perm•t Issuing f icial
r
qv
JOSEPH F. SULLIVAN, P.E.
eonauttln9 fng&mx-'
-. ....- ..._.r -... w,.y..i' .:. r,,.1'�r.,.,._va •= :::...r : i .ad'.5c.:�:.. ��,t L. �.' s .�`- F- "i�lLSl[�C'�li(..TL_.-� -- .'r �3 _-:_ s.r'.1 ^•':= "' -:.'a - '�'. -. �.. .�. _ ...._�,rs6 a—.o _ _ _ y.:o
YORKTOWN HEIGHTS, N. Y. 10598
(914) 962 -4248
�'/ "` d � J � � t ,� ,r� y�� ! �L j�'� ���'rN �y •"'ter C� i
PUTNAM COQUY DEPART OF HEALTH - DIVISION OF ENVIRONMENM HEALTH SERVICES
. INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SH= -- Cy NSTRUGTION . PJE MW ......._
_.- • DATE "'�RE�TIEW�[7: 8 `LC7 ` V 11 .r i.
v�7 �rL ABLI BY: ,
(Name of Owner) (Street Location)
DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
If PWS - Letter
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions.- Volume
D or J Box;Trench /Gallery; Puma pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
Expansion _area; shofar.; gr.-avity. £i, ow cuff .., size.
If Pumped Pit & D Box Shawn & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (Inc. expan)
15' to Drains- Curtain,Stom,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
COAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Penni.t Same
a
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
.. -..wu �... •+c' r- ._ ... -. .- : =„��:: �;' .�,� -:. -.. ��.�f:w$e:: "'= 6.. ,.-. ;e. .�.r+aa.0 '... .v � i�.'^-" ..:.,^,_,.•- �. ,is"�:. >..t+�_.�.�-= �-- :- .'.. -• _ = °w:�ti' 4t=..;
Re: Property of
Located at
(T )i� �J99 ��ection Block Z Lot
^—r
Subdivision of /
Subdv. Lot Filed Map Date
Gentlemen:
This letter is to authorize G'
a duly licensed professional enginee 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
connection with this matter and to supervise the construction of said
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.
Very truly yours,
Signed Va�, ..c�
� Si ed
Countersigne e
p Owner'of Property
P . .ate; #'
Address
Add e Town
j
Telephone
A 4
Teleph ne
I" v6o Y
0
PUTNAM COUNTY DEPAR`IMFP OF HEALTH - DIVISION OF MWMOM4ENTAL HEALTH SERVICES
INDIVIDUAL MUM SUPPLY SUBSURFACE SE kGE DISPOSAL SYSTEMS
- --
C�� DATE: L '
�►U19 � 1. 1� INSP. BY: -ice
(Name of Owner), (Street Location)
INITIAL SITE INSPECTION T (Z YES NO OCMMENTS.
Wetlands on /or proximate to property...............
Property lines or corners found ...................
Can estimate house location .......................
Will driveway need cut....... ...................
Must trees be removed - note these ................
Deep holes representative of entire SDS area......
Additional deep holes needed..... ...... .. ...
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells /septics ............................
�>
2T'
UA 0A k zzt ,
�-
YES
NO
J
House SSDS located per approved plan............
'}
Width of trench average
Slope of tile line and trench acceptable.........
D. H. 1 Lot
Depth to G.W.
Depth to rock
Soil Descr
0 ft.
3 ft. I i
6 ft.
D.H. 2 Lot
Depth to G. W.
Depth to rock
Soil Descri t
0 ft.
3 ft.
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to G. W.
Depth to rock
Soil Description
0 ft.
3 ft.
�1
6 f t. _ , �G/ c
9 ft. 9 ft. 9 ft.
-12 ft
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
House SSDS located per approved plan............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Room allowed for expansion trenches ..............
Over 100 ft. fran watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded.......... ... ........
10 ft. maintainers from property line and
20 ft. from house... .............. ...........
Distance well to SSDS (ft.)....... .............
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. fran nearest trench ................
15 ft. of peripheral soil horizontally
fran trench ..... ...............................
Boxes properly set.. . .... ........ ........
Could surface runoff fram driveway, roads,
ground surface, etc., channel near SDS area....
_
_
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE..
/I VIVkVIRO , R �1VIIZOI Iz' OMKO)Qm a
•' 0 I. 0' ' 1� Y •1
DESIGN DATA mmr -smsu ACE SEWAGE DISPOSAL SYSTEM FILE NO.
(wrier r—;1�' J7 �'e� l�Address �� T C� G/% /�f'/'� • �r
Located at (Street)��//�� Sec. 022,-,�- Block �_ Lot 2,
(indicate nearest ross street)
Municipality isG1'r� Af// W atershed
Date of Pre- Soaking / / ?c:::� /�� Date of Percolation Tes
NUMBER
C= TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water Fran
Water'Level
dez
No.
Time
Ground Surface ,
In Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
112 1�67
2Z
320
�U�G�S`� /�
4
5
a2�i� ^V`
".
2
dez
>Z
4
5
3
4
5.
NOTES: 1. Tests to be repeated at same depth until apprc+acimately equal soil rates
are obtained at each percolation test hole. All data to'be submitttd .
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
2
3
4
5.
NOTES: 1. Tests to be repeated at same depth until apprc+acimately equal soil rates
are obtained at each percolation test hole. All data to'be submitttd .
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
DEPTH ROLE NO. HOLE NO. HOLE NO.
2°
4'
5'
6'
7'
8'
91
10'
12'
13'
14'
°'IlVDiCATTE °f L `P,T =WI�^IQi Gi OONI IS' g3W@uNTEREI)
INDICATE LEVEL TO WHICH wATER LEVEL, RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: ,�� /� DATE:
- -- DESIGN �✓
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided ,561 -66
No. of Bedrooms Septic Tank Capacity gals.
THIS SPACE FOR USE BY HEALTH DEPARME T ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
V / �
.. r
2F .:..