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-PUTNAM COUNTY DEPARTMENT OF HEATH
Rev. -3186 Division of Environmental Healtb $ervlces, Carmel, N.Y.16512
Engliier , M-4
vide
P.CoH.D. Ppjmit,#r"-,';
A
011
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM j a i _:r 0
lownw'Village.
TAX
Located at .o5l,4fie M. ,
Owner /applicant %T.-- Ad Subdivision Name Lot #
MalyngAddress —J� Zip Date Permit Issued
'
Separate Sewerage . System bat by W er —Address
Consisting of Gallon Septic Tank an d
Water Supply: Public Supply From Address
A4
or: private Supply Drilled by Z16.0 Address
f
Building <JelVer—Has Erosion Control Been Completed?— let--.5
Number of Bedrooms Has Garbage Grinder Been Installed? Ale
/3 dl
I certify that the systemis) as listed serving the above premises were constructed esqentially.as'
of which are attached), and in accordance with the standaxds,�rules'ano regulations, .in acc rdan
-b�-tnam Count �rtment of Health'
completed work Cdopies
the permit issued by the
j -% . z 11
P.E. R.A.
Date artified b,-
A�ddre U
at No. ZS
"bolle system�sl act is may rrection of any unsanitary
Any person occupying premise served by th. shall promptly take such
I 1 .4 o nu ins ub(1: unitary sower becomes
AROovil- bf. that separate _!aware" system Shali become I,"
conditions resulting _�rorn, Such USR". - - -
-water i6iy itiil(�'biconiejiull and void When a public water sc, vallable. Such Approvals are
available and the-approval'!of the,private -pS�
subj act to modification - or . change -when, )n. the, Judgment ol' the' d6frimlisl0nik Of Health, such revocation m. -*Ion or change Is necessary.'
Date Title
z
ux '� `COUNTY OF-WESTCHE8TEl t
+ DEPARTMENT OF LABORATORIES AND RESFARCH I
SVALHALIA NEW YORK 1.0595
BACTERIAL EXAMINATION Of DRINKING ANO TREATED WATER Y
sL-ab No Bottle N
°_ ,Date "Coll d Time
ii
NA
C Time Set ' ;� T+me`Submttted
it
Testa (Circle `SPG Col+torni MPN Col+form Membrane, Patel Other 5„
rY
'Coll :d by aK t "Y z ra t Agency Coll d= tortst
F
Coll d from 14 a #
(I.awy�tl� IF�nq
Acd—is
Cua.1
tden0bcetion of:Source ^�
SamplingPoint within Premroea . €� Refngaiated?
Chlonnated7 Yes o NoFree
mg To +af mg /l pH
�- RESULTSOFVEXAMINATI.ON OF WATER
s
Standa-rd,'Plate Ccunt
Bactena per ml (18 nr
Col+form Group - `.;
Membranb Method/.100 MI., "
Nuber Positive T
m ubes Total Col+lorm
+
Fecal Coldorm Other• ` r
These results +nd+cete sample wa *' as not►i of Reported by = 1 Oate
sstwfactory aamtary.qual+ty-wh e= sample was
collected
,'"•(�i�
� ►�
W
WL'LL IVPirL!✓11VLV itP�rVitl
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS. WNIµI ! 1 Y TAX GRID NUMBER:
WELL OWNER
NAME: f ADDRESS:
ob
PRIVATE
O PUBLIC
USE OF WELL
1;- primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY O °AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST / OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm.INO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR .
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
D REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH - � ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING IVOPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH 6a ft_
MATERIALS: STEEL ❑ PLASTIC O OTHER
CASING
LENGTH .BELOW GRADE __di___ tt.
JOINTS: ❑ V WELDED THREADED ❑ OTHER
DETAILS
DIAMETER —2 in.
SEAL ❑ CEMENT GROUT BENTONITE ❑OTHER
WEIGHT
PER FOOT 7 _ lb-/ft.
DRIVE SHOE 16YES ❑ NO
LINER: O YES 60
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (f t)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST ; If detailed pumping
MFjHOO: O PUMPED i .tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED O OTHER ; ❑ YES 0 NO
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
well
Dia-
(meter
FORMATION DESCRIPTION
CODE.
ft.
IL
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land
Surlace
WATEfi CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ONO
STORAGE TANK: TYPE I
GAL. O
CAPACITY Z.12" 6a& F)r Argl i�.
PUMP (INFORMATION
TYPE > � L6 ;1,l�•%`� �LeICAPACITY ,�
r
MAKER 5��1� -dL(>� l 7 DEPTH ,
MODEL Z-50 VOLTAGEiP,4�
WELL DRILLER NAME DATE
BERT M. HYATT & SONS, INC.
ADDRESS Well Drilling StGfi3fiURE
Rte. 311. R. R. 2 Box 171A
PATTERSON, NEW YORK 12563
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIROWERM HEALTH SERVICES
Owner or Purchaser of Building Section Block Lot
-1/
Building Constructed by
&0,4p—le e* --
Location - Stree
Municipality
Building Type
Subdivision Name
Subdivision Lot #
GUARANM 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
"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 °2\0 day of 1/e c 19
W
General Contractor.(Owner) - Signature
Corporation Name j (if Corp.)
EZ 13KlI�
Address
rev. 9/85
mk
Title
�
I
'
Corporation Name (if Corp.)
Pe Qx l r7 K
ess
M *4
W.
V.
Vi_
r uwjjl z- L'.Ur. 1 LNZD e . X-LUN Date �J
Inserted bv,..o
;G3TICN ✓�j- aT� A ,��/ y Cw�VE�
` �- 4 OR S'JBDITISICN LCT
4
Gf kin f"N1AlUC�•...
DISPOSP.L A?��
a_ S�.S area lc—t=— as per aooroved plans
I - - - -- 1.•
b. F-;? I section - Date of lac�ut A�
P ///
2:1 barrie~ _ 7 IGM "s WZD'I'fi . (0 AVG_DP E
.
c. Natural soil nct � stri re i
X
d_ Sce=ne, brus=h, etc., greater than 15' fran SDS area_
e_ 100 ft_ from w�te_r course /wetlands.
SEEIv =-- DISPOSAL SYSTEM 1�
a. Septic tank size ,000 1,250
b- Sentic tank insi— I /'I
I
c. 10 ` mi.niimu-n f=an foundation I X
d. Nc 90° l:znds, clear-cut within 10 ft. of 45° b----d I IX
I
e. , DISZ Tj=CN BOX
1. ALl outl--+ at. same e? evat? on - watar tested.
2. Protect---- be._cw frost
3. M -Lnir LSII 2 T_= crigiPall soil be-t- e°!l box and trEnches I
I
I Qlv
f. J �tiCTICN Ei X = crcce-- ly sat
Q. %- C Sh r� '. ? red - (/ I+ mncth installed
2. Distance to water-ccursa measure -/ 3ez ft.
3. Instai lea ac=rdina to plan
I�
4. Distance caner to center
I f
I
I
5. Slcr..=- cf t `nch acceptable 1 /16 - 1/32 "/foot.
IX
1
1
6. 10. feet f_an ercrr"r line - 20 fees. - foundations J
�
7. Dentz cf trench < 30 i*iche_s free s-uxfac°_
I X
8. Rccn allcxe!E fcr Exransicn, 50%
° Size of c , -7 e? 3/4 - 1�" diameter I�
I
10. Dent_ri cf crayel in trench 12" minirm�sn - I
X
L Pine emdr CT
h. OR DCS-E SfSL rS
1. Size- of r, chambp—
2. Over-flcw
3. Ala=n, vi s-�l /audio
I
4. Puma easily acc%sible manhole to rode - i
5. Fi rs t box tfl�
6. Cycle wit_ essed by Health Demar`u-ne_nt
estimat- flaw r cycle
I
I
ECU=- I
a_ Ease lost- tx--- acorcve3 plans-
I
b. h er of bearo T s 1
I
I
WaL I
a_ W l located as acDreved plpn s
x I
b. Di 'tance free SIDS area measured 142 ft.
c. Cr since 18" ab=va grade_ I
I
I
lop
d_ S=.--ace dra? mca arcund we? 1 accectable_
I
I
G4ERA .'. WORMAS= I
a. ECYas rcpa -m- V ar cuted
b. A? ipes -r =`a:! lv backfilled (x
I
I
c_ A_ pices flush with inside of box
d. E= e'fill material contains stones < 4" in diameter
u
e_ C- ain dram installed according to plan I
x I
f- C- t-ai.n dr- n cut= all protects & dir. to eYist_wata- ccurs4 -v 1
g_ Footing drains di sctia.rae away from SDS area
h_ S`=ace avatar crate'_ tion adequate I J(
i_ E__oszon ccnLOl mrovided on sloces greater than 15 %. L •, (
I
,2)3
It
i vi u ion w,..
;:A for C.0
-of.. the
20
.37' - -3
--------------
0441
AS —BUILT SEWAGE RI POSAL SYSTEM
Co sev
SUB— DIV.
-T.M. NO. DATE
JOSEPH F. SULLIVAN P.Eo
YORKTOWN HEIGHTS, �E YORK ,
r.
y 4f- 0
SCALE AS S.H0VM JOB NO. 2,4
i.
�1
t
l(:
i1.
i
f
i�
i
i
N ��I
/"COI 10t E 09 p000CA141 e _ ....
"This is to certify that the sewage disposal system was yt., OP Ne+, R
constructed as indicated on this plan and that the system td ,
W' •' ` /
wSs inspected by me before it was covered over. The �
system was constructed in accordance with all standard � S
rules and regulations of the Putnam County Department of V "
Health and the New York State Department of Health." �F� _4,
RoFass�oN�`
- -- rG
G
f
's
3
trl� ���f'�✓ �'•
,.
�le dlr7 c
Building Type Lot Area "
Fill Section Only Depth Volume
Number of Bedrooms - Design. Flow G /P /D OG:
PCHI) Notification Is Required When le completed '
Separate Sewerage System,to'gonstat of life, 4P Gallon Septic Tank and �8 G
--
To be constructed by .... " Address
t` f
PUTNAM COUNTY DEPARTMENT -OF HEALTH
.'
'.
Revs, 316"15 /
Divislon of Environmental Health Services. Carmel, N.Y :10512
Engineer- O Pmvtde Permit N
on CERTIFICATE F COMPLIANCE`' -o— _
�/
CONSTRUCTION PERMIT FOR
AGE DISPOSAL, SYSTEM
_ : :regu ions o
n C ce" da'tisoec°tory the Commissioner of Healthwill
Permit IY.
rs, o'r or a;k�y . ,by a builder, that said budder will.
place in good operating, condition any partr of said sewage, disposal, system during the
once. of the approval of the Certificate of Construction 'Compliance of the original cyst
no tw, rsim%1e�};atei following. the date of the issu•.
y r pto;l hat'1l�he'drilled'wall described above
will tie located as shown on the approved plan and that _said well will be installed ..In cords
Located at . `
..
'
Town or VfOage
Subdivision Name
Sabd. Lot H
Tax Map -
Block Lot '
f!/r t (�/ �r�9 q1, 44% P. 9
Renewal_O
Revision
Owner /Applicant Name
_
1-15e
le o�ew e-
Date of Previous Approval
Mailing. Address
/.�"` , I
Town
yi
trl� ���f'�✓ �'•
,.
�le dlr7 c
Building Type Lot Area "
Fill Section Only Depth Volume
Number of Bedrooms - Design. Flow G /P /D OG:
PCHI) Notification Is Required When le completed '
Separate Sewerage System,to'gonstat of life, 4P Gallon Septic Tank and �8 G
L - -�� i?/ /�c° C �--g
To be constructed by .... " Address
Water Supply: '>PttbHe Supply Flom Address'
.
+
or: �" Private SaQply Drilled by _Address
Other Requirements ! R' A �/ ��! I "tvi %
.. `
e
1
1 represent that I'am wholly and completely responsible for the design and location of the pro i st�ntgsbla• tf� a separate sewage disposal system
described will.tie the approved,amendment there to in 1�� d86ds'j s'an a e Putnam
above constructed as shown on and accpr
County Department of Health, and that on completion thereof a "Certificate of Construe
_ : :regu ions o
n C ce" da'tisoec°tory the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner.
rs, o'r or a;k�y . ,by a builder, that said budder will.
place in good operating, condition any partr of said sewage, disposal, system during the
once. of the approval of the Certificate of Construction 'Compliance of the original cyst
no tw, rsim%1e�};atei following. the date of the issu•.
y r pto;l hat'1l�he'drilled'wall described above
will tie located as shown on the approved plan and that _said well will be installed ..In cords
h- h `tt rtis, ru'let,.an r91 a1 on T -the Putnam
County Dep rtment of Health.
' '�Z
..
'
Date g7, Signed L
P.Ey _ R.A.
...Address.'_.." . /.
:�.� License ,No .
M'R•l.1W
APPROVED FOR CONSTRUCTION: is approvalexpires �r from the date issued
. a
les ,, D'e1<,Ottyttiuilding tias been undertaken and is
revocable for cause or maybe amend or modified when considered necessary by the Commissions ➢any change or alteration of construction,
requires a new permit. disposal of. domestic sanitary sewage, and /or privatte...fwater, supply
%Approved.tor
Date �7r�L s�G7 Z �. /�� %BY r+
—only.
/�mc�T ltle /.
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 # fl I q
WELL LOCATION
Street Address Town /V'llage /City Tax
Grid Number
WELL OWNER
Name
v
Address 21fr ivate
, D 1 Public
USE OF WELL
1 - primary
2 - secondary
SIDENTIAL
O BUSINESS
0 INDUSTRIAL
® PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
CIINSTITUTIONAL O STAND -BY
D ABANDONED
.❑ OTHER (specify
E3
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE ,$�OG> gal
REASON FOR
DRILLING
WNIEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
❑ REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
ODRIVEN
E]DUG
®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ;--'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name l3e "ll %�� -9 Address: AI-
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES P-' NO
NAME OF PUBLIC WATER SUPPLY: '—' TOWN /VIL /CITY -'
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:,r``��
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON REAR OF THIS APPLICATION �ON SEPAR SH T
/ �s�
('dat'e) (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:1t12��c 22.1j;-_ 19
Date of E x p i r a t i on 9= `z"— Permit Issuing Official
Permit is Non - Transferrable
8/86
APPENDIX B
PUTNAM COUNTY DEPARDENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL V&M SUPPLY & SUBSURFACE SEV AGE DISPOSAL SYSTEMS
v
(Name of Owner)
COMMENTS
LF trench provided
required
60 ft. max.
Parellel to
REVIEW
SHEET
-
CONSTRUCTION PERMIT ((��jj��
DATE EWED :
BY:
ratio )
DOCUMEN'T'S 3 . (-
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc
Consistent Perc Results.(3) Fill
Perc Hole.Depth cd
House Plans - Two sets
Well ✓ permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- 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)
ewage System Hydraulic Profile - Gravity Flow
Fill Profile &(,Dimensions - Vo `7 c
D or J Box;Trench /Gallery; Pimp pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
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 Pumped Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's w /in 200 ft. of Proposed System
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,Top of f i
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expa
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercour.
Q
(S reet
YES
NO
--
y
�—
rs
,..
101. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' fram Foundation; 50' to well
I 15' Well to PL
I
I
PUI'NAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
FIELD INSPECTION REPORT
Tl< P DATE:
INSP. BY: r✓ ->
(Name of Owner) (Street Location)
INITIAL SITE INSPECTION YES NO COMMFSiI'S
Wetlands on /or proximate to property..............
Property lines or corners found ...................
Canestimate house location ....................... 1
Will driveway need cut .............................
Must trees be- remved - note these ................
Deep holes representative of entire SDS area......
Additional deep holes needed ...................... L
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells /septics ...... ............. .......
D.H. 1 Lot. D. H. 2 Lot
Depth to G.W. Depth to G. W.
Depth to rock Depth to rock _ --
0 ft.
Soil Descri tion
0 ft.
Soil Descri do
; ;' • ��u...
3 ft.
f,r:�.a
3 ft.
'
6 ft.
a > > .
6 ft.
12 ft.
12 ft.
FINAL SITE INSPECTION
DATE:
INSP.BY:
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 ..............
Over100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarlygraded ............................
10 ft. maintained fran 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. from nearest trench..... . .........
15 ft. of peripheral soil horizontally
from trench ..... ...............................
Boxes properly set. ...... ......... .........
Could surface runoff from driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK,,iri area of SDS::..... .
D.H. - Deep Hole
G. W. -Groundwater
D. H. 3 _. Lot
Depth to G. W.
Depth to rock
Soil Descri tion
0 ft.
3 ft.
6 f t.
9 ft.
12 ft.
CES NO COMMEN'T'S
:4
D •N • F ENVI• • is v •i E• «a.
DESIGN DATA SHEETj-- sumuFACE s&gA/GE DISPOSAL SYSTEM FILE NO.
owner �' T �� � �i %!ye' Z Address f�
Located at (Street) /ya'f e
Sec. Block % Lot
(indicate nearest cross street)
Municipaiity cr a
Watershed
SOIL PERCOLATION TEST DATA RDQMM TO BE SUBMIT E D WITH APPLICATIONS
Date of Pre- Soaking %r 2- 6 Date of Percolation Test
HOLE
NUCER CL= TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water Fran
Water Level
No. Time Ground Surface
In Inches Soil Rate
Start -Stop Min. Start Stop
Drop In Min /In Drop
Inches Inches
Inches
I 11 /0 - /e JZ 12, fL� �'�. %��
13.
2 ,10j2 -jo��
�/U21
/40
4
5
k C�
4
5
1
2
3
4
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 fran top of hole.
rev. 9 /85
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 fran top of hole.
rev. 9 /85
TEST PIT DATA REQUIRED TO BE SUMMED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO.
G.L. "
3'
4'
5'
6'
7'
81
9'
10'
11'
12'
13'
14'
HOLE NO. �"
HOLE NO.
INDICATE ,LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE,LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED � b
DEEP HOLE OBSERVATIONS MADE BY: ,,I ✓lei? DATEf� -,�
DESIGN
Soil Rate Used d -5' Min /1" Drop: S.D. Usable Area Provided S O 47U
No. of Bedrooms 3 Septic Tank Capacity gals. Type •�cfr�� -'"
Absorption Area Provided By Jel 0 L.F. x 24" width trench
Other
Name i c� ✓/ /� Signature
Address
40141,
THIS SPACE FOR USE BY HEALTH DEPAR2MW ONLY:
Soil Rate Approved sq.ft /gal. Checked ` t
lax:. _.. a.a9,•
r
Date