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PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev. 3 86
Division of Environmental Health Services, Carmel, N Y :10512 `
Engineer MnatProvide'-
P C H D Permit N
CE GATE OF CONSTRUCTION-COMPLIANCE FOR SEWAGE DISPOSAL SYSTEMT1assea/
_.
Located at oiler 1=�tu� 1 Ta:`Map 1 TBlocks ye 'Lot l9
Water Sdpply: Nbpc Supply From . Address
ors Private Supply Drilled by Address
F?e=s 1 Dt1:1G6 Has Erosion ,Control Been' Completed? Yens
Buffdin8 Type . - .. .
Nambei of Bedrooms 4 Has Garbage Grinder Been Installed?
Other Requirements
I "certify t:hat'tha syatem(a) as listed aerLinq the above premises were constructed- essentially as.shovn on a plans of the completed work. Ccopies
'of which'areattached),' and in. acdoidance ". with* the standards;,rules and ,regulatioha;, in' accord_ -e with filed plan,`and -the permit issued.by. the
'Putnam County Department Of Health.. -
ur�
Cetifid y
Date e b -
PE._�RA
r
A;dd►ess _� `:I� "Qsaoc�.�i'rtTs Rr .6Z GRt�le3c. r: WY License No. Z.�0008,
A,ny parson occupying premises served by the above systems) shalt promptly,take wch' action es;may be; necessary to NOure the correction of any" unsanitary
Conditions resulting from- such. usage. ' A'pproval .of : the, separate swveragesystem shall become null and void' as $oon as . a pubs-: sanitary. sewer becomes
available and the approval of the .private water supply shall beeome_nuil and,.void when a, public -water- supply bes:omas available: Such" approvals are
subJeet to modification or "change wheen.n.,in- the'Judgment of the.Commissionor of Meath, suu rr6vocation. modiflcatlon or change Is:neNsary%',c�
Date it, Is
x - SoI\
* r 71r
6[1 0
WELL I:UMYLL11UV r%LrUA1
DEPARTMENT OF HEALTH
Division Of Environmental Health. Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: , WNI I I Y TAX GRID NUMBER:
J®r
WELL OWNER
N E. � ,�
c / U�� ADDRESS: ��
❑ PBIVATE
O PUBLIC
USE OF WEL[_'5JESIOENTIAL
1 - primary
2 - secondary
❑ PUBLIC SUPPLY ❑ AIR /C D. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ...* ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT �� gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/ 0BSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft. I
STATIC WATER LEVEL ft.
DATE MEASURED a F!
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. _"'Iq OPEN•HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 3 ft
MATERIALS: "%S STEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE_ ft
JOINTS_ ❑ WELDED ',THREADED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE `9.OTHER
WEIGHT PER FOOT lb./ft.
I DRIVE SHOE ❑ YES ' SQN0 LINER: ❑ YES*fQQNO
SCREEN
D ETAI LS
DIAMETER (in)
'SLOT SIZE
LENGTH (1t)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH it.
WELL YIELD TEST If detailed pumping
P P 9
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR ; formation attached?
O BAILED ❑ OTHER i ❑ YES ❑ NO
1PIELL LOG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
Bea r
in 9
Wen
Dia-
meter
In
FORMATION DESCRIPTION
CODE
tt
ft,
WELL DEPTH
it.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Land
Surface
- LL
itl
wIT;t
WATE$ 'IS CLEAR TEMP.
QUALITY ❑CLOUDY HARDNESS
O COLORED ANALYZED? '9 YES O NO
ANALYSIS ATTACHED ?`Q YES ONO
STORAGE TANK: TYPEUKL"M U
CAPACITY --b (� GAL. LW
PUMP IHF RMATION
TYPE �� 1i~S 1 CAPACITY
MAKER - 7U DEPT o— _
MODEL �G1�I VOLTAGIHP
WELL DRlll NAM 0 TE
WELI �� I S �_-) Sv N S slGt O
�� P�mIc rd �.'�� /✓'"
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: Albert H. Padovani M. T. (ASCP)
F
TORLISH WELL DRILLING
PO Box 271
Armonk, NY
10504
1
L J
LABORATORY REPORT ON THE QUALITY OF WATER
LAB #
Date Taken: q��`�88 Time :- GY�:rm
Date Rc' d : Time: 10: m
Date Reported: SEP. 2A 1988
Collected By: Duane Torlish
Referred By:
Sample Location: an
—4ftiYV 1',g Up
meA 14 m"r-Luc y+ >ey .
Phone N 2T3 -3448
Phone N I Sample Type:
Repeat Test? _ (check one)
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
_ Acidity
_ Alkalinity
Chloride
_ Detergents, MBAS
_ Hardness, Total
_ Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
_ Copper
_ Iron
_ Lead
Manganese
Mercury
_ Sodium
Zinc
MISCELLANEOUS
- pH (units)
Color (units)
_ Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
-z"s-tandard Plate Count 10
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
_zTotal Coliform
Fecal Coliform
Fecal Streptococcus
MOST PROBABLE_ NUMBER TECHNIQUE
Total Coliform Index
_ Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
LT = Less Than ( < )
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)-
_✓Potable
_ Non- notable
_ STP INF
_ STP EFF
Other.
Sample Status:
(check each)
Outgoing
— HNO3
_ Hcl
H2SO4
NaOH
_ ZnOAc
_ Na2S2o3
Other:
Incoming
t-'LE 4 °C
_ GT 4 °C
pH LE 2
pH GE 9
pH GE 12
_ Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T NE YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTI
THESE RESULTS INDICATE THAT.THE WATER SAMPLE (DID) (DIDN'T) (N/A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA D NKING WATER
CODES, FOR THE/R.fRAMETERS TESTED, AT THE TIME OF COLLECTION.
/x/ IIN I� 2 /86(RvsdT /87)RWE
<<
Owner or urc azT�ser of Building
Building Cons.tructed by
�.bwl0� �o,� •
Location - Street
:Ek1,aV.80,%j
un c pality
Section
Bloc
Bu i ing ,..Type. Lot
GUARANTY OF SEPARATE SE14AGE- SYSTEM
I represent that fam 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 sh6;n 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 guaranty to the owner, his succes-
sors, 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 initial,use of the.sewage disposal
system, or any repairs :Wade by me to such system, except where the failure
to operate properly is caused by the willful or negligent act of the occu-
pant of the building utilizing the system.
The undersigned further agrees to accept as conclusive the de-
termination of the Director of the Division of Environmental Health Ser-
vices 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
Dated this �jTN day of 19 Signatur
Title _ Mau 0 q,
f corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE.-ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE, OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental: Health Services, Putnam County, Department of Health
I7.
r.7.
4_
FL SITE DISrECTCV Cates
Ins t� by
CNN
C,v
All
z - '21 T OR SUEDrTISIC'N ELT ` (
SFNA(E DISrCSAr
I
a SJS area lc=a _ as per a--orcvec DlanS
vt
_C: to Clarl
.
b- fill se—cL i ca - Date of plac`rzant
4.
a - ac-- = =_ =able rra_, cl= to Grace
P' a e__ _ °.
I
2:1 barrier. LG� w =Tri AVG DPI-Th-
i cz =r' ah e i - i /32
/f C: C. I I
C.
C_ bTav r-1 soil nct st=irred I
LG'LT `'_Cii °_ I `
I
d. S :�ne, brus , e_c_ , ara =fir t�.Gn lf' f -an S;�S zr== 1
S .
I
e_ lco ft_ f =a arcs -
Sizes c= craves 3/4 - l;'
c^ r=r TS EPA EYE = 1
b. cf LC_iC -`
C i:'- t_ `T c:: 12" "l T r._M"-_a
a. Ss'c•t i C t _n.1 Sze - 1,000 1,2SO
�a . u
4q I(_-C. _ t= as Car c= urc -v ed r) n c 1
b. E -nL -c t � i�� -_i level.
C_ 10' II1Zi7? it iL_i - ,:rr =_ =CIi
C. 1 90° he C''= ^CLt wit,I -i M 10 ZC. GL
1 1 l 1 c =- -- c =ra Fj cr ^- : r-r, - 4r� -^'" to S�.� -- 'j--
r i
--1-
--}
1�'l
f.
C_
2. Prot = =ea cv f_^st I I
;R i n_aLi 2 -- Cr.C1?'= C 1_ �c = Jcc ^_ CCri �� i=_Cn eS
h_ F-2-LO CR CCSC S_c sc
? Size cr r=m c =..,ter
I
D�s,�Tc� n��- ��- �:�� =•.�r�
rte. ( I I
_C: to Clarl
4.
a - ac-- = =_ =able rra_, cl= to Grace
P' a e__ _ °.
(
I
i cz =r' ah e i - i /32
/f C: C. I I
C.
10 -F=--`- _ ^-- -r—e— I irc - 20 L=== -
LG'LT `'_Cii °_ I `
i .
Dec o c= < 30 in
S .
FcCCIt cl! C:.-� =Cr Er•.c.Sl�_Ci :, .cl� �
I I I
Sizes c= craves 3/4 - l;'
b. cf LC_iC -`
C i:'- t_ `T c:: 12" "l T r._M"-_a
h_ F-2-LO CR CCSC S_c sc
? Size cr r=m c =..,ter
I
2. C-; e_r f lc-w tank I
I
3. A1�i,
a - ac-- = =_ =able rra_, cl= to Grace
P' a e__ _ °.
(
I
6. Cicle w_t__SW by H__ ___� L Cep Ent I
4
I
e_= � ? TPc L__ __C,,v par c,;, e (
I
HCuSS
a_ Ecz-e lc= -tta� rer acnprcved pla_^:s.
b. cf LC_iC -`
l
I
�a . u
4q I(_-C. _ t= as Car c= urc -v ed r) n c 1
b. Distance t_= 5LZ are= rt:_SUr=17
C_ C_S_na crac= I II
a_ motes prcr�_�i c;'c::t
b.
C_ P- p1Tr s f I L,sla wit_"1 1nsiGe ci Cam{
ins s cnss < c! lII d4arr -zt=_
e_ C. n C_c_ � =- acccrc_nc LQ Ls _r. -f
f _ C== , ? n C�C__ C L= =l 1 L�rCL�C✓= & G =r
t0
C. Fcct- ncr C_r� G= SC^_arC EDS rte+
_ e cSv��i L -r�dii a
h_ GvGl=r`C�C%�
c - ^ `.^' cr ; , 1caz cn
S+ ' CCcs C� _%r t? ^ i j 3
A019 1 -11/1 A 1) D /r _
5/i � /
�� �4.QO�itr� mar
SIDS «�--
9
e r ed arnie drn"t th m to and in accordance with ihe standa ds ru s nd r ulat n of 'the Putnam
be A '- W�Jil,-bo the owner,' Ais,su"cessliors. helrs,6� assigns or'-Will
ita
Date
Sign RE.
Lic
re a NO
eIns
APPRO V E Q FO 1� CO NST R UCTID,N.� T.h is Mp`p�S�a I ex p ir!s tw6yea! 5 Iroff�-t he date. Unless 'C'onstruction.A)f the bU'ld'n§'Lhas been. Undertaken and Is
1187. Date
Title
`
1051: Engh,—
1011109116zi of Ed N.Y.
CERMCATE
NM PEkhur,FoR,szwAGE;;Dispd
S" SYSTEM
Daft of pie-AOUS:1 proy
Yoe L
Lot FIR-Sibcdon
Now.bor d B."redin D
Deil�n Flow G -P, D PCHD NotIfteathm li Required When FM Is completed
GaBon
To be, COMIriteWl A
=T"k"d
z.
the s6pailio.m
o e descritied:wdl e
be A '- W�Jil,-bo the owner,' Ais,su"cessliors. helrs,6� assigns or'-Will
ita
Date
Sign RE.
Lic
re a NO
eIns
APPRO V E Q FO 1� CO NST R UCTID,N.� T.h is Mp`p�S�a I ex p ir!s tw6yea! 5 Iroff�-t he date. Unless 'C'onstruction.A)f the bU'ld'n§'Lhas been. Undertaken and Is
1187. Date
Title
`
DEPARTMENT OF HEALTH
Division of Environmental "Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address Town y Tax Grid Number
eY n1ocod0 °L Q b . a 1-t-19
WELL OWNER
Name
Mailing Address
D s
10Private
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT „j a gpm /# PEOPLE SERVEDI N, /EST, of DAILY USAGE avom gal
REASON FOR
DRILLING
RNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WT.1AS- S PEI-%e
WELL TYPE
DRILLED
13DRIVEN
ODUG
GRAVEL
El OTHER
IS WELL SITE SUBJECT TO FLOODING? YES J( NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF'SUBDIVISION:
1!�.t42�/��.✓ 1�/lA�.l� Lot No. S
WATER WELL CONTRACTOR: Name% Ser -� r�rt«l t� -Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES '*X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED aL�`'i'
ON REAR OF THIS APPLICATION PIRA
to ,
(date) U -. (s`.
PERMIT
TO CONSTRUCT A WATER
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 pe t.
3. "Submit a Well Completion Report on a form pro ' e by he u m ounty
Health Depar men�tQ
Date of Issue: — 7 19
Date of Expiration: 19 ermit Issuing ffic a
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange cony: Well Driller
F.-Tai 55 RIB
PLM;3M COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIROMMU HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SII0.GE DISPOSAL SYSTEMS
(Name of Owner)
REVIEW SHEET - CONSTRUCTION PERMIT
DATE REVIF'vv -ED:
BY:
(S trest Location)
• �
ESQ;
'MUM
■-_
■
LF trench J_
provided
-• .
60 ft. � ►'
Paralle
00: -
4004M.
S
100 ft
no ft.
DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
House Plans - Two sets
well permit; PWS
Variance Reauest
tar s�
s/s
SUBDIVISION
Perc e
(3) Fill
cd
L
1CtL�Y 3
Legal Subdivision
Subdivision Approval Checked
P.4- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flcw
Fill. Profile & Dimensions - Vo1Lre
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder rate)
Design*Data: Perc and deep results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shown; gravity flow,suff. size
If Purrved Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's w /in 200 ft, of Proposed Systems
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 Tre -s,Top of fit
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake ( inc. e)c .an
15' to Drains- 1--urtain, Leader, Footing
351to catch basin, stormdrain,piped watercours
10' to Hater Line (pits -20')
50' intermittent drainac7e course
Septic Tanks
10' fran Foundation; 50' to well
15' Well to Pr. 9
Putnam County Department of, Ifealth
.Division of Environmental Sanitation
AFFIDAVIT - CORPOMNTE OIVNEP, APPLICATION
FOR PERMIT APPLICATION .SUBMITTED TO
PUTNAM COUNTY FIDILTH DEPARTMENT
TO: Commissioner of Health - In the matter,of application for
- Wi -`'� -�- - - - - - - - - - - - represent'
that I am an officer or employee of the corporation and am authorized
to act .for _ .[ v_� �S! T-P - -- -- - - - - - -
(name of corporation)
having offices at. _ /Do CG_C�_`' %IQ,.e�uw���i N_ ._`�/_ /.�,�.2G /.
,,,._,___- _ /________________ Whose officers are
President ^�9iv1e 1 �• i'�r+�_��c -c - %D /loc,r� c_v%�a(- �i_or�i�- _c�041
ar
Name iniff Address)
See - jr2ew5
V4va=#@kE9EWent AV740A* 1 Y�_ /T�► -1 e u e e i 3 &i i8 Q e o," em q le., ��e o o�c1 /4/,_/
(Nanoe and tiddr•ess)
Secretary_- _____ -__
(Name and Address) - - - -
Treasurer
r- -
- - - - - (Name _ _ and Address) - - - - - - - - - - - - -
and that I;•am and will be individually responsible for any or all acts
of the corporation with respect to the approval requested. and all s'llo.-
sequent acts relating thereto.
Sworn. to efore me this =day Signed
of / 1,9 Title �N -eSir� nul_ _
No ar Publ'
' KELLY H. WILSON
- .NOTARY• PUBLIC, NEW YORK STATE
No. 4862845
QUALIFIED IN DUTCHESS COUNTY...
= ' COMMISSION. EXPIRES 7121114 -
r°
Corporate Seal
I
O
pUnm Qoum DEPAFMgNr. CP HEALTH
DIVISION OF BEAL SERVICES
DESIGN DATA SHPET�SUBSUFACE SEWAGE ' DISPCSAL SYSTEH. FILE W.
Ad�re3 pP�x' OWner c%oT.�
_ r--1Y toSI
Located at (Street) Sec. i Block. _ 1_ Lot S_
(iruiicate nearest cross street) °T 0s 5
Municipality Watershed. <
wiL PERox TION TEST DATA ,PxwmED To 8E ammr= WTTH APPLICA ms
Date of Pre -Sg king 2 2a -'se Date of Percolation Test 2• a s em5,
HOLE ;
NLPBER QACR T PERCOLATION PERCOLATIOtN
Run Elapse Depth to Water From Water Level'
No. ''Time Ground Surface In Inches Soil Rate
Start-Stop Min. 'Start. StcV Drop In Min/In Drop
Inches Inches Inches •
1 9:50 -9:09 39 2 2.4 3 Ig
29:09 -9:ro I
4L
4
3
►4
3
IS
4
24
3
�S
5 1i -tl- 12*0&
ra,
Z%
Z•4
1 e: 40 - q: 22
4 2
20
2 3
3
►-4 _
2
3
15
3 1o•o-1- lo.- SZ
46
Zo
73
3
I S
3
4
5
2JOTE5: ' 1. Tests to be repeated' at same depth unhil ,approximately equal soil rates
are ' obtained .at each percolation test hole. All data to* be • suhmitt�ci
for review.
2. Depth measurements to be made from top of hole.
RDQUIRED TO' ME , SUBNIIiZM) WITH APPLICATION
IN 2VC:SP HCVrES
urx.ruriION OF SOILS ENCC
.
DEPTH. H= ' NO. I HOLE NO. Z
HOLE N0:
G.L. .•. .
3'
I�o4r
M
4►
10'
13►
14l.
r
INDICATE LEVEL AT WHICH GPZLW WATER IS FNOOUNTERF D 1� o tit
INDICATE LEVEE, TO .WHICH WATER LEVEL RISES AFTER BEING Mooumsm
f.J
DEEP' HOLE OBSERVATIONS MADE BY: 00-
22 39' DATES
DESIGN
Soil Rate Used 11 -Is Min/l. Drop; S.D.. Usable Area •Provided, z00091
No. of Bedroans q Septic Tank Capacity gals. Type ►- .,�.,�v
Absorption Area Provided By Soo L.F. x 24" width -
trench
..
Other
- ' -���, `•
.. Name cl"i c . Signature'
s► t ► s r�-S,
Address ou74E: s'z SEAL
G..QC --\� •NYC IoSIZ ...
,��:�r't ;i' %`
' THIS SPACE FOR USE BY' - HEALTH -DEPAR211JT ONLY: