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HomeMy WebLinkAbout0241DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4.19 -1 -26 BOX 3 00050 r � w 4 Y i /0 L�4 F PUTNAM COUNTY DEPARTMENT OP'HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE 'TREATVIENT SYSTEM Ow ner• , U� Located at (street): cJr d e � Municipality: Address: TM # Section: _ Block _tot Watersh G ed• e.1 � oxzl_e,... SOIL PERCOLATION TEST DATA n Witnessed by: Date of Pre - soaking: �� / Date of Percolation Test: X ? Z. Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to . water from ground surface (inches) Start - stop Water ' level drop in inches Percolation Rate min/inch a 1 s- © a o Z A_ 6 - 55 4 5 1 l 3 4 1 2 3 4 5 1 2. 3 4 5 Notes: 1. Tests, to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < l mitt for 1-30 min/inch, < 2 thin for 31 -60 min/inch), All data to be submitted for review. 2. Depth measurements to be made from top of hole. Farm DD -97, pg I of''_ a o TEST,PIT.DATA , DESCRIPTION OF SOILS ENCPUNTE],tED IN TEST HOLES DEPTH HOLE #%I HOLE # HOLE # HOLE # HOLE #_ G.L. 0.5' 1.0' 155' a'6 U r cy,, 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 6.5 r orrJp / c;, . 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level .at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered _ Deep hole observations made bv: Date 7Z-7 �Z Design Professional Name: Address: Signature: Design Professional = Seal e SHERLITA AMLER, MD, MS,1~AAP Commissioner of Health {r Xr LORETTA MOLINARI, RN, MSN .4ssociate Commissioner of Health DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING ROBERT. BONDI County ecutive ROBERTIMORRIS, PE Director o Environmental Health All information below must be fully completed prior to any scheduling. DATE: ENGINEER OR FIRM: AJIII PERSON TO CONTACT: ❑ NEW CONSTRUCTION ❑ REPAIR PROGRAM ❑ ADDITION PROGJW REASON: DEEPS: 011-"PERCS:0' PUMP TEST: ❑ ROAD /STREET: -1,"( 6 r--A i ;f TOWN: SUBDIVISION: Oi%F'ivER:-q P CRITERIA FOR, YES NO TAX MAP #: LOT #: 0 0 Proposed SSTS within the drainage basin of "West Branch or Boyds Corner Croton Falls Reservoirs. 0 0 Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake 0 0 Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 0 ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Perm' required. 0 D Proposed SSTS for a Commercial Project. It is the responsibility of the desig)n professional to provide the above information prio to soil testing. The Department will determine the NYCDEP project status (Joint or Delegated) based on he response. If you answered ves to any of the questions, NYCDEP must witness the soil tests. This Depart nt will coordinate a mutually suitable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response a0d then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole esponsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP: Ir FOR COUNTY USE ONLY DATE: TIME: COMMENTS: R° -U FORE M- DTFS 1XG:K"- Environmental Health (845) 278-6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -54I8 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC(845)278-6678 Nursing Home Care Fax (945)278-6085 Early Intervention /Preschool (845) 278-6014 Fax (845) 278 -6648 Z-d 6869 -6LZ (SVS) i _ -_ llepuAi d9o:Z� Z6 LZ unf PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fUL completed prior to any scheduling SITE LOCATION brn TowN�� TM Y r OWNER'S NAME �S��VZG� PHONE p °% MAILING ADDRESS PROPOSED CONTRACTORIINSTALLER "HONE ;# ADDRESS l %f.� l %� � EGIS T RATfON (LICENSE # A)' Reason for exploration: ❑ failure to surface ❑ back -up in house ❑ find limits of system for repair mother Y 76 r. lain below) FOR COUNT`! USE ONLY inspectors Signature & Title Date Appointment Date: Time: a kiy,:excel:septic L-d 6969-6LZ (9t8) IIepuAi d90 :Z6 Z6 LZ unf Wate r .Supply: lL Public Supply ,From �s w. Private Supply Drilled BY, Address ss { /`ease P No.. of Bedroor Building Type - Has.Erosion 'Control Been 'Completed? e ` .I °certify that the systems) as listed serving the above premises were constructed essentially attached), and in accordance with- the- standards, rules avid regulations plans filed, and tt 73' 7V Date Certified b Address Any person occupyjng, Orem ises served by.the above Sys conditions resulting from such .usage ^,Approval' of th available and the approval of the private water supply, work (copies of which, are Ity .,Department of Health.. 7 P.E. R.A. ll # "License No. ary to, secure the correction of ar as soon as a a n. i.taI . •se ly becomes. available. Such` a subject .to- modification or :change. when, In ;the judgment .of-the-. Health,..such ev-ocati n, modification- or change ^is neces f` Date r Y BY In Title i unsanitary r becomes royals are 71 C3 Ba on 7T 0 c a Da --- 6v—� r-z T 3 E 77- i 7- rg ,117 (SEF ;CqtnILO r "hony ,a/c Poured ­191n01 9,otond-- 4 11 be 0 a, gravel, TYPICAL FILL sEcrioN FOR SLOPING' GgoUMO. .. T,,e pem IPC AN OF FIL L SECTION ,jh 4f porollel /D/ours to adddomI1d1vv1 lo zb (see. schedule) ,0, for W01 lengtt) mqwed(sec schedule) `7 JQ—T to be e,icnded to yvrface `bat fle w may be' adjulw lati-rais: ir po F'?- ,0t,6 kt� L" DAPrEk 7YPIC41 SUBMedS181f PUMP COAIAIECrIoAl TYPICAL JfT PUMP C 0 N At f C TI 0 N WELL DETAILS No T r p s c 4 L f TYPI DAIS ff -the i,1 .t �2 J. cq _7 0 -M, 9' 17, flat d' to w" , - 4" 4-1 71d iee$ m 31 S, 7,