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HomeMy WebLinkAbout4686DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.24 -1 -2 BOX 35 , r ' I,yti � �� ' I ti• I rr I ly IL I k I IT I \� P.UTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER MUST vy� Y PRO.VJ DE V Division of Environmental HelalLh Services, Carmel, N. . 10512 p •PERMIT # CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE; DISPOSAL SYSTEM Town or Villag' _ Locateq- at' (-1`L�►+ti V i�l�W+�� ., _ Taz'Map . Block. .. Cl 11 _1�i� V V i7 / Formerly Tax Map Lot A t i ,3 Subd. Lot & l 1 - IN Owner p Separate Sewerage System built by 3d (,,A L Address SPf W NJ� Consisting of 100v Gal. Septic Tank and r+-bQ Z' �I '�tk Other requirements Water Supply: Public Supply From Private Supply Drilled By Address Building Type � No, of Bedrooms J Date Permit Issue,,,,d 5 1 Has Erosion Control Been Completed? Has garbage grinder been installed? 03 I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulations, i rdance with the filed plan, and the permit issued by the Putnam County Department Of Health. Date 3 D� Certified by P.E. R A. Address -2 IVY��1_ 5 1 &1 Lice Any Y3 I3 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become nu id when a public water supply becomes available. Such approvals are subject to modification Sour change when, in the Judgment of the mmisslo r of Health, such revocation, modification or change Is necessary. Date �q12— /V BY Title eSgk'd- Rev. 6/85 PUTNAM COUNTY DEPART OF HEALTH - .a..._..__._. _ _. ,D NWENTAL HEALTH SERVIC .L-1 6 iko K rO 1 A- Owner or Purchaser of Building Building Constructed by Location - Street Municipality - -� Building Type I% I d , t.3 Section Block Lot 11 L 6 -2 Subdivision Name Subdivision Lot # GUARW= 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 years immediately following the date of approval of the • "C. rtificate-_of .-Construction -:Compliance ",^ for:.the, sewage. disposal, .system, •�or, an y> . repairs made by me to `such system, except where the failure to operate poperly 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 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. Dated this day of 19 Signature Corporation Name (if Corp.) COA4 Address rev. 9/85 mk Corporation Name (if Corp.) ! RL Address ►I`Y- ^~_^.� DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM..EOUNTY.DEPARtMENT .0 WILI WELL LOCATION Ziuly qi 3 1.3 WELL OWNER NAME . ADDRESS. 37 .2-PBIVATE USE OF WELL 1 - primary 2 -secondary 2RESIDENTIAL 0 PUBLIC SUPPLY 0 AIRICOND./HEAT PUMP - 0 ABAN/0ONED 0 BUSINESS 0 FARM 0 TEST/ 0 BS EIRVATION 0 OTHER (specify) 0 INDUSTRIAL 0 INSTITUTIONAL 0 STAND-BY ED AMOUNT OF USE YIELD SOUGHT S_ gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING Pl]�EW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY 0 TEST/OBSERVATION 0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 32 o ft. STATIC WATER' LEVEL _4_,_L_ ft. I DATE MEAS_ URED 7 DRILLING EQUIPMENT -G�-_AOTARY- 0 COMPRESSED AIR PERCUSSION 0 DUG 0 WELL POINT 0 CABLE PERCUSSION 0 QTHER (specify): WELL TYPE 0 SCREENED 0 OPEN END CASING. 3-dPEN HOLE IN BEDROCK 0 OTHER TOTAL LENGTH _tL MATERIALS: WTEEL 0 PLASTIC C3 OTHER CASI NG DETAILS LENGTH.BELOW GRADE ft. JOINTS: 0 WELDED Ci-THREADED 0 OTHER DIAMETER in,. SEAL: 0 CEMENT GROUT 0 BENTONITE 3ZHER WEIGHT PER FOOT I lb./ft. DRIVE SHOE: &�ES 0 NO I LINER: 0 YES OM SCREEN DIAMETER (in).* 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? DETAIL FIRST HOURS GRAVEL ACK 0 YES GRAVEL- DIAMETER TOP BOTTOM WELL'YIELD TEST It detailed purn ing p METHOD: PUMPED tests were done is in- O'COMPRESSED AIR formation attached? if more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE Water pear- Well Dia- NELL DEPTH DURATION DRAINOOWN YIELD Land surlace /0 h ct, 0( 6 Oka, 6i.,olep.- VATE9 0 CLEAR TEMP. UALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES ONO IT AkER(gir4o,44-1 DEPTH .7 10 -/V01rft,V de r7 ADDRESS SIGF19MRE YYorkto n Medical Laboratory, Inc. LAB # 321 Kear Street Tiffie° ° Date Taken f� �% Yorktown Heights, N. Y. 10508 Date Rc -° d �. -:,Time- Di °D i a R� ort ed . —'--AUG-2'Q 1987 P Director: Albert H. Padovani M. T. (AS Collected By • • r Referred By: C��ZaSS2d�rDS /���i2��y/ ✓— Sample Location: &J" i vl Phone N �Ko4l Phone # Sample Type: Repeat Test? 1(ciheck`one) LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA Standard Plate Count (CFU /1.OmL) (Agar Plate 9 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT) ✓otal Coliform (CFU /100mL,) Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /100mL) MOST PROBABLE NUMBER' TECHNIQUE (MPN) Total Coliform: MPN Index (per 100mL) - Fecal-Colitorm:"MPN Index (per 1OOmL) OTHER ANALYSES REMARKS (For Laboratory Use) _.,--Potable _ Non - potable STP INF STP EFF Other: Sample Status: (check each) Outgoing Na2S203 Incoming �LE 4 °C 4 °C _ Other: KEY FOR TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC =.Too Numerous To Count CON = Confluent.( =TNTC) LT = Less Than (< ) GT Greater Than (> ) N/A = Not Applicable LE = Lean than nr enval to THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS))(WASN °T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH W.//YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS- TESTED,.AT THE TIME OF COLLECTION. For Lab Use Only: Mel- _ H/C to' Albert H. Padovani, M.T. (ASCP), Director 12 /85(Rvsd7 /87)RWE ILAB OFFICE HOURS (Main Lab): 9AM -5PM, Mon. -Fri. 9AM - NOON,. Sat. APPENDIX C -( F._NAL SITE INSPECTION Date (�• G�u�NER Y ,::...Inspected 11 e--._ ry....:r • -° �12.�1' V• ^::�./s�- J'�b�lC��i:st: hs1�1:=.Ji.JL. �" � 4'.:: .. .•��. -.��,. .: YES NC7 rrnRn rG. 'frSc R SE4v DISPOSAL PREP a_ SDS area located as per approved plans -- b. Fill section - Date of.plac--nent 2.1 barrier . ICCTH WZI7I'Ei AVG.DPTH c: Natural soil not st; inced d. Stone, brush, etc., greater than 15' from SDS area. e. 100 ft. frcin water course /wetlands. I v II. S'T.nu= DISPOSAL SYST ---m a. Septic t=nk s_ze 1100 11250 b. Septic tar-k lnst_1 i e��el C. 10' min' nam from fcur_daticn d_ No 90° hands, clez -Tout within 10 ft. of 450 rz ^_d ^ / FJ -' V Q/ I I e. DISTRLL-TIGN FAX 1. Pi I outlets at same elevati cn - water testes 2. Protected L^e, aw frost JS..�. 3. Minimum 2 .ft. original soil he vieen box and t_`nches ( / f. at%- .TION EOX --prc--erly set I g 'LREtiGHl�S �� 1. Length rem, -- — Lz_n��n it = = =l lea. s� Q 2. Distance to wat= rcCLse me s-urr-E f t. 3. L-Lastalled accor(iincl to plan 4. Distance center to center 5. Sloce of trench acceptable 1/16 - 1/32 L*ide--- 6. 10 feet fran nrcte--ty line - 20 fE-zt - feur_dati cns 7. Depth of tae ach < 30 inches fran s-,=face I 1 5 1 I 8. Rocco allowed for exransien, 50% 9. Size of gravel 3/4 - li" dizmet_r 10. Depth of g=avel in trench 12" mini= ( i I ..11 ..Pzr,,,zcs_C�rZ�`7 h. PURP OR- i3OSE - .CYST- S - _.. •) 1. Size of pLup charrb, r .. _.. 1 2. Over-flaw tank 3. Alarm, visual/audio I I I 4. P= easily acce--sible manhole to erade I I 5. First box baf led I 6. Cycle witnessed by Ee l h DecEx,-tme_nt I estimated. flea per c• ,7cle IV. SOUSE ' a. Ecuse lcc.ted rx--- anoroved plans. b. Nun:- of bearca.5 V. W-E L ' a. Well lecat,--d as aooroved vlars I . ! I b. Distance frcin SDS aree me-asured IOU ft. c. Casing 18" above grade_ i e_ Q. d. Surface drainage around well acceptable. VI. GV&RALL WORIMASHIP a. Boxes ror�erl grouted b. A11 2i2!-,s *-`tia11v hackfilled j I I .c- All Rires f1Lh with inside of box I I d. Faccf.ill material contains stones < 4" in diamet`r e. Cl r°tain drain installed according to plan f. Ourttain drain cut=all protected & dir.to exi St_wat�rCJUrs�,�` --- g. Pectin draiP� disc arce awa fray SDS are= I i h. Sue =ace water rot= = --Lion adept -.ate i_ -, csion cor_tro provides on slopes rat =r the* 15 ;. i �^ PUTNAM COUNTY DEPARTMENT OF HEALTH 1 /X 8 Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit # {itrv, on CERTIFICATE OF CO COPISTRU PI PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit PERMIT 5. 11 Located at_ _ �'. — LA�\� ..- �_ .._. _ �5l a. :.iii °'•'./►,4'� ' r QR D..,^^ T'�i' Y +. : t.. s.1 .4 ' -1.. � .C.:�+P^xx- w Sam. ! st..C! . _T � . D - ,►.�°'' j"' +?y -. Subdivision Flame yi'r7 *c-��N�1'�' Snbd. Lot # y Taa Map Bloch —Lot C9�� Renewal_❑ Revision p Owner /Applicant Flame l t Date of Previous Approval Mailing Address 2,-M l.0 i/a ht- Town Pic t\* III— zip `0 3 Building: Type wtr, Lot Area Fill Section Only Li Depth Volume Plumber of Bedrooms 3 Design Flow G /P /D Coo I PCHD NotiOcatlon Is R!S When FIB is completed Separate Sewerage System to consist of n Septic unit an ©Q l D ty To be constructed by u' Address Water Supply; Public Supply From_ or: V/ Private Supply Drilled Other Requirements 1 represent that I am wholly and completely responsible for the design and location of the proposed system(f); 1) th the separate Sewage disposal system above described will be constructed as shown on the approved- amendment there to and in accordance with the standards, rules and regulations of e Putnam County Department of Health, and that on completion thereof a 'Certifica&oConstruction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be turnishe his successors, heirs or assigns Dy the Duildor, that said builder will place in good operating condition any part of said sewage disposal syst peri d of two (2) years immediately following thedats of the issu- ance of the approval of the Certificate of Construction Compliance of. hte or any s thereto; 2) that the drilled well described above will be located.as shoavn on the aDProved plan and that said well will De instal ne with st lards, rules and regu a ions of the Putnam County Depa tnl nt of Health. � Date Signed P.E. / ✓R.A. Address 4, t& License No 1373( APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued nless construction of the building has been undertaken and is revocable for cause or may be amended or modified when c ider d necessar the Commissioner of Health. Any change or alteration of construction requires anew permit. Approved for disposal of do i ry seq�ci/opzlvate water supply only. Date _(6!_ �,i P B Title . m vaucr.,nvywromon�e � h..':' . represent hat+ am wholly and - completely h 1. represent a wilYbe constructeO'as show, 'i County Department of Healfli; and that on bo •submdtea•'to the Department- and a wii y w i place �n good "operating condition any pa i. ante of.the'.dpproval• of the Ceitificate :of -.i will b located as ' e show_ n- on 'the approve, plan :.,, County Depart exit f :Health. . Date_ D, fiL APPROVED FOR CONSTRUCTION Thii al revocable 'for • cause .or. may, be amended Or me requires a ne permit. Approved for dispo Date l/ ✓ i' . / % .O a R d.thaY aitl.wellwlll;be ' instbl :in arc nce,wi the ?s Signed Z 5� ��nvt ile :�iy roval expues,,one year;!from the i "'date isd ed unless`constr if when consi der'ed'nacegry,Dy the",Commissioner "oil I of domestic 66e, wate r(s► 1).,that, `the - separate sewage disposal.'system, . a sianddidi, rules an regu a ions,o a a., `u narn e" satisfactory to•tha'Cornmis ;ionei'of Healthwill Mrs or assigns by the builder, that said :builder will yea ►s'ImmeGiately'follovving thelaterofthe_issu ;, ,• rs'there +•2) that tKe'drilled +well. described, above kd ds, led, and requa ons .o( .<the Putnam_ . P.E. v R.A. _License No T�r `�►� ,tion of ,the building "has been undertaken and. is lealth, ' Any change eooraaiter /atio�n: of construction manly. , • !� 'i" • / - Title IS-.WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Vu c.N -- LOT NO.: `(1 -loy WATER WELL CONTRACTOR: Name'. Le ss: IS PUBLIC WATER. SUPPLY AVAILABLE TO SITE YES _ NO 5��5•' - DAME OF PUBLIC-WATER SUPPLY: TOW-N /V /C DISTANCE TO PROPERTY FROM NEAREST WATER. -MAIN LOCATION SKETCH ,& SOURCES OF CONTMIINATION. _ S�. � Sec. • P�,:; - - �- ' . lu 2l 4S 6 (date) (signatu . 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: le Pump the well until the water is clear. 20 Disinfect the -iwell.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 :�/ Permit Issuing Official Permit is Non- Transferrable STREEI WN /VIL / 1 .Y QdX (iRiU NUMBER. WELL LOCATION IELL.O�dNER NAME: "Cre�A ADORES : Coo S PaO� '. IAu ��claell� . VY. 10 %05 BISIVATE O PUBLIC USE OF WELL B ESIDENTIAL O PUBLIC SUPPLY O AIR /CONDAEAT PUMP .O ABANDONED I - primary O BUSINESS ` . ; O FARM O TEST /OBSERVATION . O,.OTHER: (specify) 2 -'secondary O ffiOUSTRIAL. ...O INSTITUTIONAL O STAND -BY AM®UNT. OF.USE YIELD SOUGHT ® ° gpm /N0: PEOPLE SERVED y / EST. OF' DAILY USAGE gal. REASON FOR NEW SUPPLY.. O: PROVIDE ADDITIONAL SUPPLY. O TEST /OBSERVATION DRILLING O flEPLACE EXISTING.SUPPLY O DEEPEN EXISTING WELL a•, .W ELE TAPE D DRIVEN, DUG D . , GRAVEL OTHER C� � IS-.WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Vu c.N -- LOT NO.: `(1 -loy WATER WELL CONTRACTOR: Name'. Le ss: IS PUBLIC WATER. SUPPLY AVAILABLE TO SITE YES _ NO 5��5•' - DAME OF PUBLIC-WATER SUPPLY: TOW-N /V /C DISTANCE TO PROPERTY FROM NEAREST WATER. -MAIN LOCATION SKETCH ,& SOURCES OF CONTMIINATION. _ S�. � Sec. • P�,:; - - �- ' . lu 2l 4S 6 (date) (signatu . 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: le Pump the well until the water is clear. 20 Disinfect the -iwell.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 :�/ Permit Issuing Official Permit is Non- Transferrable PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEDGE DISPOSAL SYSTEMS AgE a+o ^DATE - REVIEWED: s� BY: �� -• -� (Name of Owner) (Sfrerdt Location) COMMENTS YES I NO DOCUMENTS Permit Application Corporate Resolution k 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 v--' /°'° Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow o d 2 U 3 q X 5 Fill Profile & Dimensions. - Volume D or J Box;Trench /Gallery; Pump 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•- Arear; shown gravity' flow;-Are--.' size If Pumped Pit & D Box Shown & Detailed ` 3 x House - No. of Bedroans /� ,o G �5' 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 k No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields X 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- Cartain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks rr' 10' fran Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland ( Town /DEC Permit R & D) Data On DDS Plans & Permit Same Re: PUTNAM COUNTY DEPARTMENT OF HEALTH 7 _.-,D.JVIS-I .,OF-ENVI-RONMEUTAL.HEALTH SERVICES Property-of- VI I\ Date . I . A) .111 j16 'k (k_ Located at cts 13 (T)�, Section 91_Blockj_Lot Subdivision of %e Subdv. Lot # Ct 10 Filed Map # C Date J-32/19-6 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 .'-,:_.._.conn . qp,�ipn:-­.fkth. this matter and to-SUID-P-rYl . L.Se. th 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 ,o Owner f Property Countersigned: P.E., R.A., # Address Zq Z Address Z6 Telephone Town 'Telephone y �'� _ j..w Y '4 t1_ 1 }S S � , .ems •� DIVISION OF ENVIRONMENTAL.HEALTH'SERVICES John M. Simmons, M.D. :Deputy :Commissioner.-of Health FIELD - ACTIVITY S_ EPORT IN I TELEPHONE PERSON IN CHARGE OR INTERVIEWED DATE �l G TIME ARRIVED Construction _! Reinspection _ Field, Sampling Only. Field Conference Name and Title Other TYPE FACILITY ffn ��GS S % o� TIME LEFT FINDINGS: ` yi -It. vt r Lf/ 7'1,1 s :7.f, Explain n .e• cam, i Ci / � � "i /.I r .�, : /.r — –YYi .� .✓ J� c X ��J c�.••c � � �' /'S .!3 �• %� ' �? /! /y? %i � � C3i _ r s .-� .off/ •✓- //i .�'=n Ih, a r� 7! rx J! i.;.• •� ' /f INSPECTOR: Signature and= -T"itl PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this Field Activity Report ................... SIGNATURE: TITLE: TELEPHONE: iy INSPECTION: NAME Orig`. Routine Orig. Complain. ADDRESS Orig. Request No. Street Municipality (T)(V)(C) Compliance " ' `O r �–� — Complaint Comp MAILING ADDRESS U / G, //j Final . P.O..Box Post Office Zip Code — Group Illness IN I TELEPHONE PERSON IN CHARGE OR INTERVIEWED DATE �l G TIME ARRIVED Construction _! Reinspection _ Field, Sampling Only. Field Conference Name and Title Other TYPE FACILITY ffn ��GS S % o� TIME LEFT FINDINGS: ` yi -It. vt r Lf/ 7'1,1 s :7.f, Explain n .e• cam, i Ci / � � "i /.I r .�, : /.r — –YYi .� .✓ J� c X ��J c�.••c � � �' /'S .!3 �• %� ' �? /! /y? %i � � C3i _ r s .-� .off/ •✓- //i .�'=n Ih, a r� 7! rx J! i.;.• •� ' /f INSPECTOR: Signature and= -T"itl PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this Field Activity Report ................... SIGNATURE: TITLE: TELEPHONE: F. 0110 boo �L41l ID-0 C DIVISION`, OF.. MWM . SERyicEs _: "g �' w DISPOSAT� SxS' Fn No Owner. 'Trb: a Address Cot �1�,,,` _ • I A ►� �w• oci� el le Ny Located at (Street) Malt . �6• Oe I, L %e, '10 Rbj Seca `l Block 1 Lot J j+ ►.'�, ` • ::(indicate nearest cross street) 77 t C ZZ Municipality, > Watershed SOIL PIIZOQLATION 7EST DATA RWD3ft TO BE SUB[ rrM -WITH APPLICATIONS Date of Pre- Soaking Date of Percolation Test HOLE NUMBER CU= TIME - ": PERCOLATION PEROOIATION kun' Elapse Depth to, Water From Water' Level No. Time Ground Surface. In Inches Soil Rate' ..Start Stop .Min. Start Stop -'Drop In Min/In Drop Inches Inches Inches 1.. 30 23'.. ��h ��l� 1.K -5 4 2 30 3. -4 30 N 23 2!) 2.O. NOTES e' =� tip. • Z1es s. die repeated' at same''depth until appradmately .equal soil sates aireo'bttaih�d'.at each 'percolation test. bole A -1 data to`.be submi ttad - Depth4easurenents, to. be made from top of hole. G.L., 2' 30 40 50 60 70 80 99 I --------- 7-7- o 12 13 IS AT imm GROUNOWM INDICATE 19VM TO MC.H mm, LOB' MM AM BEING RMM!EEM DAM - DEEP HOLE ERVATI ONS, MADE BY. 7 • DESIGN Area Provided zl� Drop..- S.D.. Usable Soil Pate used._.l Min/l Type gals- .Septic -Tank Capacity of .•.Bedroans Absorption Area. Provided -By other ol Signature • Nam Sm Address cl* JY:- MS SPAM •TOR USE --BY HMM Soil Rate Approved. . ........ _Yf),l 00, RenNSnce N A 14 ti A io 4t/ AREA: 0.7583 acre 8, '00 1p ?Jp rtify that the sewage disposal system was f L as indicated on this plan and that the inspected by me before it was cover- he system was constructed in accordance rule S ' and regulations of the Putnam Court- nt. of Health-0 ♦ GuLwLy UtlYdl'LWtllIL Us ntsa.LTh Frederick A. Zenz IVIX. of Environmental Health serviose 292 Main St. approved as noted for conformaxwe with Nelsonville, N.Y. -IO5WPPlioab1e Rules and Regulations of the I ;.i J. I As Built survey by R. J. Kihlmire, L.S. It at SEPARATION DISTANCES IN FEET 71"; 'D 12 AS-BUILT SEPTIC PLAN prepared for ANTHONY TR(7 1_A MAPLE RD. SCALE: 1 %40' TOWN OF PUTNAM VALLEY 9/j3/87 PUTNAM COUNTY. N.Y. rte 6a 17� 9 1 ". 13 91 .