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HomeMy WebLinkAbout0007DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3. -1 -7 BOX 1 00007 I,fyL � Jme I� �� �' � ! � L rr a yl , No I � rI I. � . 6. I III Ell 0 00007 'WELL COMPLETION REPORT Office Use ;On y * DEPARTMENT OF HEALTH : , ay 4 Division Of.Environmenta1 Health Services " PUTNAM- COUNTY DEPARTMENT OF HEALTH } t t4% °. TREcT A0URE5S. luWNIVILLA.EaLIGIlY T AX liRlO NUGtB ' ry ELL.LOCATION 1AME::_:. ADDRESS. r� p P6NaTE NELL DINER �,k: PUBLIC;: 1SE OF YJEL RESIOENTIAC' O PUBLIC SUPPLY O _AIR /CONO./HEAT PUMP : 0-ABANDONED nma O BUSINESS D FARM D. TEST /OBSERVATION O OTHER jspeclfy) sez condary O INDUSTRIAL O INSTITUTIONAL D STAND -BY p fix_. ,. IOUNTtOF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY-USAGE"gal. REASON F0Q REPLACE .;EXISTING SUPPLY TEST /OBSERVATION, ❑ADDITIONAL` SUPPLY; -fgNEW SUPPLY NEW DWELLING) ❑DEEPEN EXISTING,WELL, DEPTN DATA�1-g_; �,. � WELD DEPTH ` ft. STATIC WATER LEVEL `eft. DATE MEASURED' "'DRILLING O , ROTARY =e.COMPRESSED AIR PERCUSSION' ❑ DUG 4 -N",; EQUIPMENT =t `D WELL POINT D. CABLE. PERCUSSION O OTHER ( specify) i"T 1V WELL.TYPE p SCREENED O OPEN END CASING -OPEN HOLE IN BEDROCK:: ks OTHEA std ;; ` TOTAL LENGTH ._.k. MATERIALS : :'�iH.STEEL 0 PLASTIC ,AO OTHER' 1111 3 f FRI FCASING LENGTH BELOW'GRADE ft.' JOINTS ' -`. D WELDED�9,THREADEO' O OTHER' DETAILS DIAMETER in: SEAL'QZEMENT GROUT O BENTONITE' OOTHER WEIGHT PER FOOT Ib. /it. DRIVE SHOE464ES O N0 ; ;;;;LINER :0 YES O w0 SCREEN f DIAMETER (in) SLOT SIZE LENGTH (IQ DEPTH TO SCREEN (it) OEYELOPEO? 1IETAjLS {l4 FIRST _ ti .o rES `O N0 y SECOND HOURS GRAVEL PACK a YES GRAVEL DIAMETER TOP [,,O NO t{ SIZE: OF PACK _ in. DEPTH R DEPTH-, It. IEEE` YIELD TEST: pumping I�JELL LOG 11 more detailed formation descriptions or sieve analyses If detailed are available, please attach. , ETH00: b PUMPED tests were done is in- ALA .; t DEPTH $UR FRO6T Water Well 6.COMPRE$$ED formation, attached? SURFACE Bear. D +a- FORMATION DESCRIPTION ,� : CDOI? BAILED ,.:`.O OTHEA . i ❑YES NO It.. It. u+9 Imeter v LI. DEPTH. DURATION DRAWOOWN YIELD Surface tt. - hr, min. It. gpm. v : .6K . -4, �V 777F ^ ARP ATEA`7BrCLEAR TEMP. 71 Yom' IAUTY'_-, CLOUDY a � HARDNESS ., COLORED ,ANALYZEO? _'tMES ONO' ;euet vsiS ATTACHED?,YES ONO STORAGE TANK : TYPE��,- y—C'(V,j`,,. ATIOH °, '': CAPACITY WN 4_�;0 GAT,.' CAPACITY WELL DRILLER N41AE DEPTH. AO R 5 GUAM VOLTAGA HP ti's V44\z- ts\ :.: i. YML ENVIRONMENTAL SERVICES r 321 Kear• Street Yorktown HeiZhts, N.Y. 10598 x .- ( 914) 245-2800 00 Albert H. Padovani,:Director a;0 0It. CLIENT #: 114 NON.;TAT PROC PAGE NNN ---- - ------ ------ --- --- •I /.I iJ --- ----- II---- NNNNNNIINN NNN NNNNI NS w IRATE /TIME TAKEN:_'.. 08/02/:94-`,Fl f. DATE /TIME RECD 08/02/94, WAYNE TORLISH REPORT DATE :: 03i08 94ry 10504 PHONE: (914)- 273- 3440 �. E: AMICUCCI DEV. 9 SAMPLE TYPE.'.��: PU' >' FAIRVIEW MANOR PATTERSON PRESERVATVES: °NOf TOR I L;13H, . TEMPERATURE.,;,..: ra GULIFORM,METH :�M _ __.,. r ;NNN NNNNNI�/INa //•� /�— ---- -- ------------------- NNNNNNNNNNNNN N/ E `� FLAG PROCEDURE NN RESULT NORMAL. FLANGE 08/9'4 MF T. COL_ I FORM ABSENT /100 ML ABSENT. >. RESULTS INDICATE THAT THE WATER WAS (WAS NOT) CIF' A ACTORY SANITARY QUALITY ACCORDING'' THE NEW YORK STATE A' FEDERAL ,DRINKING WATER STANDARD , FOR THE PARAMETERS AT:k' THE T I Mt OF COLLECTION. z --------------- - rani, M.T.(ASCP) FLAP# t' vry r .s 31; PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building Building Constructed by Location - Street A 1 Municipality Building Type f 13 Section Block Lot Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE_ SEWAGE DISPOSAL SYSTR4 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 Compliance" for the sewage disposal system, or any 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 L day of _1� 19� ' teneral Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk • - - ii/ rA VOM.", .. T itle S. /-JD Wr t s ?f /455 o c . Tiy c_ Corporation Name (if Corp.) � essh 5le AJ1417P 19/,Witi3 /N_ (/, 1060Y- SSA S i 0 !I 2 3 4 S -7 ELL 31 4i 5 52 75 h 84 65 g-7 NO M7, PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services. Carmel. N.Y. 10512 PERMIT FOR SEWAGE DISPOSAL SYSTEM Engineer to Provide Permit III on CERTIFICATE OF , AMPL[ANCE -= Permit # JF Q ...-5.La _ Town ey- Willap Subdivbiou Name 1dat2.J I Q,J 1-44-b D R- Solid. Lot 9 ,Tea ®= Map Bloch Lot 1 R Owner /Applicant Name �- IOt-tE '�J T6 f� S� G ° �8° � C3- Revision ❑ Date of Previous Approval Mailing Address I'. D . IBEX 185 Town -79 em L,/O. -o, - l.lY Zip I aS94 Building Type Lot Area 2.48 AG. Fill Section Only Depth Volume Number of Bedrooms 'Q Design Flow G P D 8OO PCHD NodBcadon Is Required When Fill b completed Separate Sewerage System to consist of /? 0 Gallon Septic Tank and SOD L. FS - & -ZSQWF r1 Del _7i2A-_tilCl4 To be contracted by / 2 B c ^L7 e3r tc'�eMrwla� Address Water Suppb,: Ptmiic Supply From Address or: �-Private Supply Drilled by --/90 S71>'1_Address Other Requlrements i�, sTet I�6Lt1r(o"j Z- 1 represent that 1 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 with the standards, rules an ►ego a Foos o e Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years immediately following the date of the issu- ance of the approval of the Certificate of Construction Compliance of the original system or any repairs reto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be Installed in accordancr the sta ads, rules and regu a :moons of the Putnam County Department offs /Hjea�llthh. (� Date j [] j� I kiLd` signed P. E. R.A. _ !^= Address� License No 2G099a APPROVED FOR CONSTRUCTION: This approval expires two years from the date iss unless construction of the building has been undertaken and i revocable for cause or may be amended or modified when considered neces by the mmissioner of Hsalt . y change or alteration of eonstr n requires a new permit Ap v fo.r disposal of domestic sani ry s e, antl /o to wa p n %87 Dater cr BY Title FLJ1111M COUfHT DEPAR1TARNT OF HEALTH ' r DlvYae of Riarkamiseeded Health Sereleae. Carmel. N.Y. ISS12 Rialignew to Pawvlde PWMK g ` ole CERI FLCATE OF COMPLIANCE 3 j CO118 MMIN !mil' FOE 3XWAG9 D1 OUL STS M 140ged./ MAI, a L a n ��T'C�'zs ®lam Name FLA"IS%4 IA4 0r- c.e..t. p Tax Map 3 • Block I Lot 1 o...r /Appresut Fiore Home -std /�`�>�� rteoe Roviell I on p Ga P,L.� �t,0 D Late of Previous Approval `r /I Nome Adhuss �'L F� 1 Town Wg l S" e_ t'14NI S 22p L".05, D ivo S' Date Subdivision Awvroved Fee Enclosed ❑ Amn„t,r � �j) tJ�� F/SI`1(.ly ,sea 2.•'i�7b smam * Depth vabu►e ype Nu Ebbw d in wsms "1 Design Flow G P D om© t PCHD Noftsdoa b Required When Fill is osnpketed Sspeear Seweespa System to eseaebt of J -Gallon Septle Tank and q o C) Lf I.13SoE? ft "Fete}{ Ter be oseledwcb -by-TO 131 '261, Address Water Ssppi psltre Sup* Ftess, Address an X Private Sw* Deified by TO V� ( .duress I reprefent':that 1 am wholly and completely responsible for the design af% location of the proposed system(s); 1) that the separate sew disposal astern above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns O nam County Department of Health, and that on completion thereof a •Certificate of Construction'Compllance" satisfactory to the Commissioner of HMtthwill be submitted to the Department, and • written guaranty will M furnished the owner, his to s. MMS or ions by the builder, that tale builder will pYte M good Operating condition any put of said as disposal system during the two (2) ya immedlatey follOw{fg tMdata of the isu- ante of the approval of the Certificate of Construction Compliance of the origi sy any ratlairs t *to; 2) that the drilled well described above WIN M (Doted a$ ~a on the approved plan and that said well will be Installed in a' r ith the sta rd% rules and rpu �%TZns Hof the Putnam County O rtr/t�aat of Health. Date '�j Signed P.E.- R' Adana GiiSH�� I�SSb�I/s'[N� �� �� License No-0180P APPROVED FOR CONSTRUCTION: This approval expires two years from the dat Issued unless construction of the building Ass been undertaken and is revocable for cause or may be amended or modified when considered necessary by he Commissioner of Health. Any change or alteration of construction requires a new permit. Approved for disposal of domestic unitaryaawage, private water supply oply. Rev. 10/88 Oat@ �1 // By Title tS _Z DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #1- 2'0 WELL LOCATION Street Address Town/Village/City Tax Grid Number r'I,&Ij�1z pa s.o-?-j S. -- t- -7 WELL OWNER Name Mailing Address ESCf��S�CZI S Z Co88t,W1f LD R2 W fIA�s rivate 0 ubl is USE OF WELL 1 - primary 2- secondary RESIDENTIAL 0 PUBLIC SUPPLY D BUSINESS O FARM 0 INDUSTRIAL U INSTITUTIONAL Q AIR /COND /HEAT PUMP 0 TEST /OBSERVATION 0 STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT M1,.j gpm /# PFOPLE SERVED, I ffiM_/EST. OF DAILY USAGE _& Sal 13 REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION Q ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING)- D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DUG O GRAVED OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ft( rV( r14-40c, Lot No. Oi WATER WELL CONTRACTOR: Name To 'W Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �NO NAME OF PUBLIC WATER SUPPLY: IJ blk TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: T14A n/ I M ( L'F_ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED QON SEPARATE SHEET ( at ) (s ature) 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 thirt3, (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. 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: �W' Pw�- --- Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File P' copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 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 0 /—;0 qi WELL LOCATION Street Address p $4 t-lo Town Tax Grid Number a -J 1 --� l .- 19 WELL OWNER Name Mailing o S--re ws-- c I- Address , 'Private 13 Public USE OF WELL 1 - primary 2- secondary )q RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL 13 INSTITUTIONAL O STAND -BY O ABANDONED 0 OTHER (specify, O AMOUNT OF USE YIELD SOUGHT Hitit 5 gpm /# PEOPLE SERVED t F,ar -t /EST. OF DAILY USAGE g� gal REASON FOR DRILLING NEW SUPPLY OREPLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY 13DEEPEN EXISTING WELL 0 TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE DRILLED DDRIVEN DUG []GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES 'C NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ;✓.a.i�y���,./ M,�loa� Lot No. WATER WELL CONTRACTOR: Name �3c" j� ,�,�,,,,ti� -Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: 9,I .,t TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:cjjPzft,%,_r=p � LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED . []ON REAR OF THIS APPLICATION 0 E$AR97 i 0 AA Wu', (date) PERMIT- TO CONSTRUCT A WATER WEI,r "Z� ~�"` 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 s.hall: 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 y e P nam Co my Health De tme t. Date of Issue: �� 19 Date of Expiration: 19- Per Issuin Official Permit is Non- Transferrable Whi copy: H.D. File Yellow dopy: Building Inspector Pink Copy: Owner 2 87 orancrp mnv! WP11 nri 11 ar First Floor C2ARAGE DECK zx'% 12' ED BREAKFAST AREA ITS GHEN us% w-9 %1 I x2 . FAMILY ROOM F.e TA i m OF EEALT, ndr :J Floor,; , -� D F OR _ `V . iz atu- &. Title --_.. Date; ININOn12' 6" \ z CL. 1 ♦\ ORCN auR All room dimensions are approximate. Developer reserves the right to substitute materials of similar quality without notice. Fairview Manor • Money Hill Rd., RR 2, Box 348A • Patterson • N.Y. • 12563.914- 878 -4480 Exclusive Sales Agent: Resource Planning Concepts, Ltd. First Floor GARAGE in iI BREAKFAST AREA KITCHEN .-9�� DECK 2Yx12' FAMILY ROOM 19' -Vx, IV i I I PAHM L _ D 1 LAUNDRY J VORCM DINING ROOM I�I=10x12 =6" L FljTNAl"i 0 Vli.i.1 E a PM':i;.ii J d.i 1,8 R4 Floor. ; , D , 6C' vvu:;T 0:rl i� �II�I�iiJ 4w 1 All room dimensions are approximate. Developer reserves the right to substitute materials of similar quality without notice. Fairview Manor • Money Hill Rd., RR 2, Box 348A • Patterson • N.Y. • 12563.914- 878 -4480 Exclusive Sales Agent: Resource Planning Concepts, Ltd. 05 O U PM M COUNTY DEPARIM. M OF HEALTH - DIVISION OF ENVIROIMAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEMGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT DATE w��� BY: (Street Location) DCCrJME'^fl'S Pe_ -,-mit Application Corporate Resolution Puns - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth �� q s/s SUBDIVISION Pere & a (3) Fill cd House Plans - Two sets Wei 1 perm; t; P4v� letter Variance Reauest =AL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Welland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Swage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pty pit derails 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/GGutter,Curtain Drains (disc~iarge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow, Buff . size If PL=Ded Pit & D Box Shown & Detailed House - No. of Bedrooms 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 Trs°.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. ex an 15' to Drains - C=urtain, Leader, Footing 35'to catch basin, stormdrain,vioed watercours 10' to Water Line (pits -201) 50.' intermittent drainage course Seotic Tanks 10' free Foundation; 50' to well l C Glcl 1 4— nr Q I � a EE® Immmommin 11110M ' -1111 ■ required .1 N am MINI1101 GEMS _ mine a . W __ 0NE MAIM mum `t s i 0 mom 1 ._ .. =oUM1 1MI_ t r DCCrJME'^fl'S Pe_ -,-mit Application Corporate Resolution Puns - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth �� q s/s SUBDIVISION Pere & a (3) Fill cd House Plans - Two sets Wei 1 perm; t; P4v� letter Variance Reauest =AL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Welland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Swage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pty pit derails 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/GGutter,Curtain Drains (disc~iarge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow, Buff . size If PL=Ded Pit & D Box Shown & Detailed House - No. of Bedrooms 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 Trs°.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. ex an 15' to Drains - C=urtain, Leader, Footing 35'to catch basin, stormdrain,vioed watercours 10' to Water Line (pits -201) 50.' intermittent drainage course Seotic Tanks 10' free Foundation; 50' to well l C Glcl 1 4— nr Q Putnam County Department of Ifealth .Division of Erivirorimental Sanitation AFFIDAVIT - CORPOMTE ONNER APPLICATION FOR PERMIT APPLICATION •SUBMITTED TO, PUTNAM COUNTY FIEALTH DEPARTMENT TO: Commissioner of Flealth - In the matter of application for �—�c_(— — — — --- — — represent that I am an officer or employee of the -corporation an.d am authorized to act .for — — 1-)o rM es i T- Cy55bclfw Se5 . _ _ — _ — _ _ _ (name of corporation) having. offices at — /D_�o��cG ._______________ __Whose officers are President —,k/V' . / ice— ic� -rc c-t �ocK�fi4t:�u_�?o(_ Name anT Address) - See -7"10 , Akn_le N e ey 3&i it5- eiCyz- 4 (mAt Rye rt7'�cooicr 1l 4'y (Namte and Address} _ Secretary--___- -- (Name and Address) — Treasurer - - — — — — (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'-* ll sub.- Sequent acts relating thereto. Sworn'.to efore me this day ': Signed of, 19�� Title nnyuSir� nac/ — -- -C-------------,--- N6f ar ' Public • = KELLY H. WILSON NOTARY,. PUBLIC, NEW YORK STATE No. 4862545 CHESS QUALIFIED IN j2�� 71iCOMMIS ON EX IRES DESIGN DATA SHEET- SUBSUFA+CE SEWAGE ' DISPO:SAL SYSTEM" FUZ NJ. owner mess o. £ek /B5 i-IVA O.Ob, t jy Located at (Street) Ma�1n� >z�, of M Sec-' �Bock � Lot tA 4 ( indicate nearest cross street)'. LCrT u° .. , ftudcipality f s-T-r� ,.1 Watershed (a oro,f 80m' PtRgx ATICN TmTnATA,Pq7jmm, TO BE SUBHrTID7 WITH APPLICATICNS Date of Pre -SQ6 k g z Zs -8g Date of Percolation Test s HOLE NUMBER CLOCK TIME PERCOLATION PEItt70LATIC�N Run. Elapse Depth to Water. From Water Level No. 'Time Ground Surface In Inches Soil Rate Start-Stop Min.. 'Start. St6p prop In Min/In prop Inches Inches Inches • 1 B�OD - f0:5q 1'1.4 Z 1 24 � • 58 2 io:s9 -1,.s9 �8c� 2I 211 3 �o 3 t 5.9 - `i 54 q 2 )f 0-7 1" i `7 22 2 5 3 59 2 i o-t - z': 0 7 1 2z �3 • .. 3 Coo 3 z =o'7- S :cn /so Zz 25 3 Gv 4 5 2 4 NC7rES : , 1. Tests to be repeated at same depth until .apprcximately equal Soil rates are 'obtained ,at each percolation test hole, All data to' be . suLadtted for review. no.-,t h ma;; ,qm- xna n t s to be made f ran too of hole* a DEPM 4 G.L. TEST PIT DATA REDUIRED To BE 'SUBKITT m WI1S APPLICATION HOLE • NO: I 3' 4' HOLE NO., HCLE' N13. r 10' 12•' 13' 14' INDICATE. LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL -RISES AFTER BEING ENOO TTERE D rJ DEEP' HOLE OBSERVATIONS MADE BY: ;e s Pe,2 iii E'D ' 1 -I,u.P a'l= zz-&�9' ` DATE: DESIGN Soil Rate Used 4(0 - &o MirV*l" Drop,-. S.D.. Usable Area Provided No. of Bedroans 4 Septic Tank .Capacity 12 7 gals. Type r4aw^(Ay -Absorption Area Provided By 889 L.F. x 24" Miidth trench Other can o - u r A L Name,asN tai ATE s P. c Signs r_ Address SEAL • •C�i�R MELD NY ICS f 2 /� ^�� : b ^�� �•\: ' THIS SPACE FOR USE BY' HEALTH •DEPA OMY: P ' n � t N Sg, t3750,- a4:'- .w' -CCr T/[ K `. / '1 �'v �' � '. �` DlrvTft,tPSt171On1 $� �i�'• �2� _ � F • � ' ��, � ' Via' c • \ � ` � /\ ✓`V t t `O i 1 C `' y r WALLS 4' THICK fi �