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Home My WebLink About4521DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85. -1 -21 BOX 34 04521 r '�, r .i . jr 3r - �, Y 04521 1 5 'A ENGINEER MUST \ PUTNAM COUNTY DEPARTMENT OF HEALTH ,PROVIDE ✓� 4%\111 Division of Environments! Hera /th Services, Carm% N. Y. 112 PERMIT # ` /��t /` CERTIFICA F CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Town or- Vill,ags `a Via_. - -.. ..•fin -� `tr . r�".'% Tax Map A t ... �-.'�'--�.:: -:i. �.�,a� ---.: .,,qa ..- ....`: '•-., ; .r =-.. . -. .. .,. _ ",- . .M1 - �� a+ Blocky � Located at - % Subd. Lot # � �^ / Formerly Tax Map Lot I! ,/� owner Be:,,r 2 1 ��l i` IR N TC� Addreu g:Z Separate Sewerage System built by ; ; Consisting of �y Gal. Septic Tank and T Q� Other requirements water Supply: Public Supply From Private Supply Drilled BY p/r Address Building Type r�� No. of Bedrooms. Date Permit Issued Building E►g Ty Control Been Completed? — Has garbage grinder been installed? 4 Of Ilfly p I certify that the system(s) as listed serving the above premises were cons t �eje�.•,l� ��d`o�y$��tf- i°0A the plans of the and the copies of which are attached), and in accordance with the standards, rules and rag t9bneC ?KX" �r�l� Putnam County Department Of Health. V. P.E. R.A. Date Ce �fied by m �� /�t }G{ I �iJYI t. =ham R License NO. Address Any person occupying premises served by th bove system(s) shall promptly tak tt conditions resulting from such usage. Ap royal of the separate sewerage system available and the approval of the private water supply shall become null and Vold w sublect to modification or change when, in the judgment of the Commissioner of By Date POTNAM COUNTY DEPARTMENT OF HEALTH Peimit s Division of Environmental Health Services, Carmel, N. Y. 10512 -SUVA GE. Q1SP(KKL 9?- T'tM'_; ... _ = own or Village `j Tax Map /�O Z Block a. Lot ivy to secure the correction of any unsanitary as soon as a public sanitary sewer becomes Y becomes available. Such approvals are modification or Change is necessary. V- PERMIT -FO Located at _ Subdivision _ Owner/Address./J �� // 4;2V �/- Building Type _ /T �/� v J Lot Area Number: of Bedrooms — Design Flow G /P /D rl e Separate Sewerage System to consist Of /2V - r, Gala Septic Tank To be constructed by Water Supply: Pytsllc Supply From P*r,1vate Supply to be drilled by Address Other Requirements Renewal _ Revision 13 Date Of Previous Approval Fill Section. Only 0 _ P.C. H. D. Notification Required y and Address 1 represent 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_approvetlt amendment -there �to-and''in "accordance with the stantlards, rules an regu a ions o e u nam County -- -Department' of" "Health, "anG that on completion thereof a 'Certificate of Construction be submitted to the Department, and a written guarantee will De furnished the owner, his tisfactory to the Commissioner of Healthwill Place in good operating condition any part of said sewage disposal ss0%s, ssigns Dy the builder, that said builder will ante of the a system during the ! aj�d�3.y mediately following thetlate of the issu -. approval of the Certificate of Construction Compliance of the original sy m - .�wu..,� will be located as shown on the approved plan and that said well will be installed in actor ce • j the =ds_ ru )standtre drilled lied Of scribed b v .�Ounty Department Of Health, l" de 21, t � Si ned r/ P.E. w R.A. Adtlress y FOR CONSTRUCTION: This a License No. approval exptr one year from the date issu ie for cause or may be amended or modified whe cons ecesse. by the C r :'�a Qte building has been undertaken and is permit, Ap rove for tltsposaI of dome is san)ta sewaee. ane✓�. o � y change r alt ation of construction n. tq Rerf: 3186' PUTNAM COUNTY DEPARTMENT OF HEALTH 4� ionof Environments' Health Setvlcer, Carmel, N.Y. 10512 IDIvis Eng)neee Mart Prov 40QJ2 � C°.I(' I,S � ,3 $��.e� P.C.H.D. Perml4rY- CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEW. Owner /applIcant Name -- Y �� , � l® If r s Formerly Mailing Address A-8 Zip i ey GP% y U3� Separate Sewerage System built by Address Consisting of % �y Gallon Se tic T alf and SSe Watery= --- -----_Public Supply From � Address or: — / Private Supply Drilled by Building /i �i� Address g �'Pe • � �� CC Has Erosion Control Been Completed? Number of �!' .... Bedrooms _ �/° Has Garbage Grinder Seen InstatledY v Other Requirements —+ i certify that the system(S) as listed serving the above .( of which are attached), and in accordance with the stands eruleeeandcrequ]ationse8 n 11 Putnam County D Partment Of He lth. Date it COrkilled by Address i�� Town or village T" Map —_Block - -_Lot le, 1 A- Subdivision Name T/y$ _V_ Subdv, Lots ",I— Date Permit Issued zo / Q 0, W. oar Any person occupying premises served by the14%e Systems) shall promptly talks resulting from such usage. Approval of the separate sewerage system shall available and the approval of the private Water supply shall become null and void When subject to mo �cp� �or Change when, in the judgment of the Commissioner of Health, Date! /� By 4� 51`11 !i ins of the completed work ( copies plan, and the permit issued by the P,E. R.A. License No, 2 r✓g9-c— 'e tho correction of any unsanitary a Pub,'!-. Sanitary Bawer becomes I available. Such approvals are in or change Is necessary. Titlo PUH1dA1bY . • . ' _. - ._ ._ _ _,.. a..r. rd.�? •� COUNTY DEP F HA I eer to Pedee y�� exstls Services. Caael N.Y. PY 1 0512 � CA PEIIIi1dPf FOR SEWAGE DISPOSAL SYSTM Sstbdivielon Name - — _ , Otrner /Ap )that Name -�r ?5- Lot 0 Peamit otral or e Tax Map ftne al —o Revision Date of Previous Appmval- Zip 2o Town Q /5'3 Fm Section Only Depth Volume Building Type l ► G� i L/J �' Lot Area Wben Fm Is comp / o o PCHD Notification 16 Rea)aleed Number of Bedrooms..'''''' Design Flow G P D e''( ) -Z Gamin Septic Tank an ell 6 0 separate Sewerage System to consist of To be contracted by G% W �� Address Water Su PP Y: Public Supply From .,� . L _d,ae Supply IM ed by sadroar Other jReettuhements I represent that 1 am wholly and completely responsible ova the the et pnaof design and above described will be constructed as shown on the aDD County Department of Health, and a completion Do furnished hed thf be submitted to the Department. Place in good operating condition any part of said sewage disposal sYStem tl inl ance of the apD►ovnl of the Certificate of Construction Col will be st the n will be located as Shawn on the approved plan and that said well will be Ind County Department f Health. 5I gned o jDate Address G APPROVED FOR CONSTRUCTION: T approv wo Years from th date expires t t _...... o ;an when considered necessary 1) that the separate sewage dis oral system ndards, rules a' n�regu a ions o e u nam lafaetory to the Commissioner of Hsalthwill r signs by the DuiWer, that tall builder. will Irs medlately following thedato of the isw ere ;2) that the drilled wall despibed'atlove d� ides and regu a ions of the Putnam _P.E. R.A. NoLy �1�f s S of the building has been undertaken and is h. AnY change Or alteration of construction nnw- .w .�lL�• :L -t; :lam +Y• "^` ...r,. _ - ...q�µ`:i. x: t��u' T. ::: A-= 1t-• vvv.` Y. 7i.:. 3? w�N. Ndyi7tic= �a. �: �,x��:4::': *i',:i...�!G:..•�;: --=- _ WFLL_•COMPLETiON REPORT - t DEPARTMENT OF HEALTH #* Division Of Environmental Health Services d9M• ? = M?TNT °t7 UNLI _ — - �:; - WELL LOCATION STREET ADDRESS: (OWN /VILLAGEICIIY TAX GRID NUMBER: WELL OWNER NAME: ADDRESS: iv B-PBIVATE ❑ .EUBL1C USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED - ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ AMOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING VNEW SUPPLY = ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH aZ b ft. STATIC WATER LEVEL VT) ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY 111- 00MPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. U1 O15EN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH � ft_ . MATERIALS: CEL ❑ PLASTIC ❑ OTHER LENGTH .BELOW GRADE ft. JOINTS: ❑ WELDED 01,THREADED ❑ OTHER DIAMETER in. SEAL: pfCEMENT GROUT ❑ BENTONITE 1 "ER WEIGHT PER FOOT Ib. /ft. I DRIVE SHOEJ;�(fS ❑ N0. I LINER: ❑ YES 04460 SCREEN DIAMETER (in)' SLOT SIZE LENGTH (11) DEPTH TO SCREEN (ft) DEVELOPED? DETAILS FIRST: O YES No . . HOURS Y _ •, - - - GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in_ TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST It detailed pumping i P P 9 METHOD: CAMPED 7F-4 r 1 tests were done is in- ❑ COMPRESSED AIR , formation attached? ❑ BAILED ❑ OTHEfl ; ❑YES ❑ NO WELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- i "9 Well Dia- meter in FORMATION DESCRIPTION COoE tt. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gpm_ Surface a V a o -SOO SCA "SA - t • 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 CAPACITY MAKER DEPTH MODEL VOLTAGE HP WELL DRILLER NAME DATE ADDRESS StGt1)fTURE A.-Y q �e A, , P ,.I" V4 /I Yorktown. Medical Laboratory, Inc LAB !,`,r o 025034, 321 Kear Street York town.Heights, N. Y. 10S98 Collection Station Used I1�45,2 Carmel Pgeitakill;- _ Director: Albert H. PadovaniM. T.(ASCP) yWt`:" Disco _ �Nev City j-. Date . Taken: Date Received: 3-,r Cti1 Date Reported: 7; Collected By: Referred By: /i Sample ,Source : 1, L �� 73-9-- 1?7 LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER. GENERAL BACTERIA Standard Plate (Agar plate MEMBRANE FILTRATION Total Coliform Fecal Coliform Count per 1.0 ml� e 35 °C) TECHNIQUE (MFT) . Der 100 ml a ner 100 ml Fecal Streptococcus per 100 ml MOST PROBABLE NUMBER TECHNIQUE (MPN) .:_ _.. -Tot= a- 14 Fecal Coliform: MPN Ind -ex per 100 ml OTHER ANALYSES �QS THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING 0 TH NEW YORK STATE DRINKING WATER STANDARDS THE PARAMETERS TE ED AT E IME OF COLLECTION. , FOR ST , T LEGEND Albert . Padovani, M.T. ASCP), Director RDS Recommend Disinfect- ing Water Source < Q less than TNTC - Too Numerous Too/ f Building Constructed by S Location —Street j 4W,-, Municipality Building Type. A6, / -i� J�5 Subdivision Name Subdivision Lot # GUARANM OF SUBSURFACE SEWhGE 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 �,.:..... :_ -repaii�'made y -n-- a- 'sgc�- syst�� - 0-xcer` fro -�i�: gaiiure tc�:op��t�� rMpe y 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 Environmental 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 buildin utilizing the system. Dated this day ovq��— 19.,� Signatur Title /y e, General Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk /'7 i / /-I f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES Z Owner or Purchaser of Buildine Section Block Lot Building Constructed by S Location —Street j 4W,-, Municipality Building Type. A6, / -i� J�5 Subdivision Name Subdivision Lot # GUARANM OF SUBSURFACE SEWhGE 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 �,.:..... :_ -repaii�'made y -n-- a- 'sgc�- syst�� - 0-xcer` fro -�i�: gaiiure tc�:op��t�� rMpe y 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 Environmental 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 buildin utilizing the system. Dated this day ovq��— 19.,� Signatur Title /y e, General Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk /'7 i / /-I f a PUTNAM COUNTY DEPARMM OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES DISPOSAL SYSTEMS INDIVIDUAL %MTER SUPPLY/SUBSURFACE SE'1 _ 'W'A`GE y t. .,e_... .• ..'1 •r , i / �� " .� .�n� �'� �{.l: �ci u�i •- ._�'�i�P1LJ1\i 'i\1..eS\O1R1' �. .. .r... .9 .. .— \ ^ °X ?r ' cr0 A 0 `�r r DATE: a; J -��- 5 4/, INSP. BY: (Name of Owner) (Street tion) /� C INITIAL SITE INSPECTION YES NO CANTS Wetlands on /or proximate to property .............. Roan allowed for expansion trenches .............. Over 100 ft. from watercourse .................... Property lines or corners found .................... Natural soil not stripped or SDS area unnecessarly graded............ ... .......... X Can estimate house location ....................... Distance well to SSDS (ft.) ...................... Will driveway need cut....... .. ......... ... Number of bedrooms checks ........................ Must trees be renpved - note these ................ Stones, brush, stumps, rubble, etc., greater Deep holes representative of entire SDS area ..e.. than 15 ft. from nearest trench........ ..a... Additional deep holes needed.,...... .. ..... Boxes properly seta... ..a. ................... Sufficient SDS area available considering.dr'veway could surface runoff from driveway, roads, cut, house location, separation distances, tc..e. ground surface, etc., channel near SDS area.... Adjacent wells/septics .. ..... .. ... .... ?oes lot drainage appear OK in area of SDS....... Access to proposed well location for drillin . D.H. - Deep Hole G.W.- Groundwater D.H. 1 Lot D.H. 2 Lo D.H. 3 Lot Depth to G. W. Depth to G. . Depth to G. W. Depth to rock Depth to r Depth to rock Soil Descri tion Soil c i tion Soil Descri tion 0 ft. 0 ft. 0 ft. 3 ft. 3 ft. 3 ft. 6 ft. 6 ft. 6 ft. 9 ft. 9 ft. 9 ft. DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS located per approved plan ............. Length of trench measured '3 7G. Width of trench average z 6" Slope of tile line and trench acceptable......... /� C Roan allowed for expansion trenches .............. Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area unnecessarly graded............ ... .......... X 10 ft. maintained from property line and 20 ft. from house... ................a....... Distance well to SSDS (ft.) ...................... Number of bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench........ ..a... L5 fte of peripheral soil horizontally from trench .................................... Boxes properly seta... ..a. ................... could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... ?oes lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE... as PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at e•--- Date ep 0 i W/2210%9 (T) Section Block Lot Subdivision of' SY4 �i �� Subdv. Lot Filed Map # Date Gentlemen: This letter is to authorize 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 connection with this matter and to supervise the construction of said orml, Y,14T eft U1. o or oiisi.m 0 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Address 5?V >, Telephone Very truly yours, Signed " Owner of Prbpeebojl S2. Address Lt LA-epw '-/ Town ,..2 If- //.SIX Telephone Ns. • Countersigne P. E. Address 5?V >, Telephone Very truly yours, Signed " Owner of Prbpeebojl S2. Address Lt LA-epw '-/ Town ,..2 If- //.SIX Telephone h'TlsT,b CIIl.C,K I;1 ST. . ,- Date: kyY INTTAL SITE D- 13PL'CTI011 Yes No Comments Property lines or corners Sound . . .. ✓ Gan estimate house. location • . . . . ..: _ Will driveway need cut ✓ Nrust trees be removed -note these . . __. ✓ - Is deep hole representative of entire SDS area Additional deep holes . needed. . . . . . . . Sufficien SDS area available considering driveway cut, hous-- location, separation distances, etc . . . . . . . . . . e DEFY IIOLE DATA Water el.eva.ti.on: Rock elevation: Soils descr_i -A on: ,L.(W _AiJb- - Date. FINAL SITU Ii'MPI31 C`1_10 X, Insp. by: House located where 'shovn on approved plan SDS located where approved . . . . . . :irngth of tranch measured • irl_i.dth of trench aver =fie Slope of tile•line and .trench.acceptable . Room allowed rforn_. expansion trenchQs -rcourse o1i . Tn _dl � . ,.. Natural soil r_ot.stripped or SDS area tm.necessarily graded e 10 Fb. maintained from prop.line.and 20 ft. from house • o • • Sep, ration of trench from house, well etc ...... follows.._ plan Number of bedrooms checks . . . . . . Stones, brush, - stumps, rubble, etc. greater. tlmn 15 ft • from nearest trench . e 15 I`t. of peripheral soil horizontally from trench . . . . . . . . . . . ... . . Junc• -ion boxes propeily set Could surface run off from driveway, roads., -ground surface, etc. channel near SDS area• s , • • • • • • e • • • • o • a e o o Does lot a.prdar 0. K. in area of SDS FINAL GRADING OIL, SITE .ACCEPTl1BLr,, o of 0 PUTNAM COUNTY DEPARTMENr OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE$,, , / f V �/ ifs � r � V Owner or Purchaser of Bui ing J/ Building Constructed)J by Location - Street '/ u /451�Ow ? /% Municipality ' i Building Type Section Block Lot Subdivision Name Subdivision Lot # GUARAib= OF SUBSURFACE S&QGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, wor)ananship, 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 .Coompliance'� =-for- then -sews 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 19 General Contractor (Owner) - Signature Corporation Name (if Corp.) 130 x >77' a /2> Address /47- Y N- rev. 9/85 mk Signature ANZZW, r.i 4 Title Corporation Name (if Corp- Address V PUTNAM COUNTY DEPARTMENT OF HEALTH _ - .DINTS -II�N OF. FN.VIRnNMF,N. 'AJa ;H LTH -; SF.L�t`J:I.CE Re: Property of Da t e 1'31;- CC %'d�7 Located at �e"� S Zre'e Section J>z Block Z. Lot J Subdivision of �iv%�` ✓�:°.,? o^iSS�f� Subdv. Lot ## Gentlemen: Filed Map ## Date This letter is to authorize °j /" °� °/ / 0; 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 4.onnection_:�'tiT� ttti�s 'm�t-- eod =,moo- serv.eyt�rcq?�crtl;#d.o':-.'o .. " ^ti '�:5. �•a».,.. -.moo. ,.•.r- _ .. .,r�s, .�. '.._ ,,,,... 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. �rs C o tei� Very.truly yours, Signed OwH6k of IV6pe-71ty Telephone Address �V\ a Town Telephone ♦ % t a " PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES T7 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM / FILE NO. _L Owner i / Address Ile- Located at (Street Sec. % Z2- Block Z Lot n lca nearer cross street) Municipality, -'- Watershed SOIL PERCOLATION TEST DATA 4fQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Elapse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 11io Z.2- 1 75 %� 5 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 from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH- HOLE NO. N0. HOLE NO. G.L... ✓ � 6" 12" r _ 18" 2411 30 30 ►� 36" 42" 48 ►� 5411 60" 66" 72 7811 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED ti I EL TO Wf�C i.XATEP- _LFVEL.:R S,ES -AFTER -BEING ENC.E- UNTEREID �``• .� ..�" � .`D.�� . .. ••aDa�.e, �� . �. _:� .... a r - - DESIGN Soil Rate Used__j Min/1 "Drop: S.D. Usable Area Provided°`�'ad No. of Bedrooms septic Tank Capacity Gals. Type Absorption Area Prov ded By =L.F.x24 width trench. Other Address �-i ®.. VA THIS SPACE FOR USE BY HEALTH DEPARV ENT ONLY: Soil Rate Approved Sq. Ft /Cal. Chec RECEIVE® SEP 2 : 1984 PUTNAM COU,,I f Y DEPT. OF HEA1 E H P M Date tv'7 7F N 44 Oftris ;I'd .to :Certj -as in ivds, I nspea t ed k. ns a ;� system,ws co I A4, 4" T.- ..7 is -41- 4 y that the soi�a�e d3:`f j- cat Ad 'd n.'t h k6t a. A', ap -me ief�ie" iti-A-was -bc .lot eil" �-j V 9W. — a Z-4w 77 7 7F N 44 Oftris ;I'd .to :Certj -as in ivds, I nspea t ed k. ns a ;� system,ws co I A4, 4" T.- ..7 is -41- 4 y that the soi�a�e d3:`f j- cat Ad 'd n.'t h k6t a. A', ap -me ief�ie" iti-A-was -bc .lot eil" �-j A". .A — a i by A". .A 14 y'6• ., :d eitnam County Depaxtwent oY heal. - division of klnvirotunental Health Seri approved as noted for conformance wii L r'r ,ppl.icable Rules and Regulations of 1 •t , ' { :.!.1 F .I Putnam Co r Healt Deparyt/ment.. 41.anatnra A, Ti l., o n , t