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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.19 -1 -4- B OX 2 Ai ' t6' ., ` 1 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR OWNER'S NAME pfz. fbVy "rJ Fi PHONE 119 - 6-78'- 90 Z SITE LOCATION P ^ft f1- 2--.J -8 MAILING ADDRESS Rout i1 Z9 Z �•°.t�vr -� PERSON INTERVIEWED PC ID Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER A. PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. proposal owed Proposal Disapproved _ ("KhetIt 491UQ 14 Pik Inspector's Signature & Title ronosal annroved with the followinq conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to beorm>ed in accordance with the above proposal and conditions. I, as owner, or SIGNATURE IPg:: V&te MD); agree to the above conditions. '. 11 TITLE 19iviKreI.EA, E,rJ- yW6--C -r- --DATE 7 Vi C ., r VoUamt) : rj 103 VARIJ • Wei A a, UVA 2 1140"N I Z A v •► • l 0+�•. DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner ,At- Address 2 % Z5 Z APPOt.oX . 2ro' c.,cs r o � Located at ( Street) fyLs Z9 L JN tti i , Sec. Block_ Lot 8 (indicate nearest cross street) Municipality PA6oA/ Watershed SOIL PERCOLATION TEST DATA RBOUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking �v�A Date of Percolation Test o HOLE NUMBER CL= TIME PERCOLATION PERCOLATION Run 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 9: Q0 - q ## S0 30 ^rte Z Z " Z $ �� ' S a►�ry /.t�G H 2 4?:3o -/0 '-00 30 M//y ZZ ". 28� 6' S n„rvla.Gt� 3 5 1 �:1� ' %�� ZyM1�• ZArr Z2. rr Z rr !S /tiiv�tt.G�% 2 Q. 4S :10 l S 30 AVAy Z0 Z ! %t %t, ri 2,0 ,s,.,v /TvGN 3 4 5 1 2 3 4 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. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION IN TEST DEPTH HOLE NO. HOLE NO. D Z HOLE NO. G.L. SAn-A y s�lw�OY 1' �.oA�'► Go�9 2' 3' 4' SA?VO S � 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED mil/ -A INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �✓iG c i�r.✓� �T, ,B,C /GK [rte Xl /L�2 DATE: q 9 0 DESIGN Soil Ra Min /1" Drop: S.D. Usable Area Provided No. of Bedrocros is Tank Capacit gals. Type Absorption Area Provided By L.F. x 2 trench Other Name T.A.SlTL? &A4/n6Sr�¢&.k V .0,9S/iiv A t f . Signature Address 7( eAA2- -MA elbC- SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date �OLJTf- 29 z- FE p6E? --rrcr--64- c1YPi p} 1c, F-x L Ir-4F- e>tp I-C Tb-f I (n er-- F L,4 rl i r-'^l WFLL L LiHF- rlk;-4rbtZ EXISTING t t T^ Y- e-L,l r-1 I Tu --JtWEJ2 LINE ) , Df2, Wff-I-L- (TT-P) Udb 1, 91t, EXISTING t err. : .,.,2 ,�- --."e- I , . ,. � �� , -- . I .. ; . ... -- , -,-- - �1 ""'�'�'�"� �!.'� I I, t '.. 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