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HomeMy WebLinkAbout0305DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -1 -53 BOX 4 I FIN or a I I IN ., 1 'T� 1 r . L 1. �. Jr 1 *1.' �� I.� � 'i 00114 Rev : 3/x.6 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Envhronmental Health Services, Camel, N.Y:10512 (�.,` Engineer Mast Provide P,Xx D Permit N y� CER OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM - — A cn -tn .Located at Owner /applicant Mailing Address Town at -V ge Tax Map I Block I Lot • v Sabdlvlslou'Nam Subdv. Lot # Zlp_ 16)S,9 Date Permit Issued Separate Sewerage System built by / ®�T Allylin," &'> Jat.0 Address Consisting of t L150 Gallon Septic Tank and 7 Water Supply: Public Supply From Address �,� y� r J or: %C Private Supply Drilled by AddresspU ! PL'JiM "ZI fi ..7 . Building Type Has Erosion Control Been Completed? �o Number of Bedrooms 4— Has Garbage Grinder Been Installed? Nil Other Requirements I certify that the system(s) as listed serving the above premises were of which are attached), and in accordance with the standards; rules an, Putnam County Department Of Health. 1!/ Data certified qY Address tially as shorn on.th plans of the completed work ( copies Ic,co �rd h th f ed plan, and he permit issued by the P.E. R. A. 1 {,�-� �'1L_I ` License No.A1574> e Any person occupying promises' Served by the above systems) shall.promptly take such action as may be necesury to secure the corrWIon of any unsanitary conditions resulting from such, usage. Approval of, the separate sewerage system shell become null and void as soon as a pub!': unitary.sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification of change �wwhen, . in the Judgment of the Commisslo' dw �of Maul h, such revocation, modification or change Is necessary. M1 Date � � C_ �l �� By T we in II. IV. V. VI. APPENDIX C FINAL SITE INSPECTION 2 ce� OWNER M1 # OR. SUBDIVISION LOT # Date Inspe ted by - L COMMENM SEWAGE DISPOSAL AREA a. SDS area located as per approved plans b. Fill section - Date of placement 2:1 barrier. LGTH WIDTH AVG.DPTH c. Natural soil not stri d. Stone, brush, etc., greater,than 15' fran SDS area. X e. 100 ft. from water course /wetlands. SEWAGE DISPOSAL SYSTEM a. Septic tank size - T,000--- b. Se tic tank installed level 'All c. 10' minimum fran foundation d. No 90° bends, cleanout within 10 ft. of 45° bend X e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX - properly set g. TRII�ICEiFS 1. Len r ired - C� !� Len installed /k" Distance to watercourse measured: -- -ft. 3. Installed accordipq to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 " /foot. q' 6. 10 feet from proiperty line - 20 feet - foundations 7. Depth of trench < 30 inches frcm surface 8. Room allowed for expansion, 50% 9. Size of. ravel 3/4 - Jill diameter -YL 10. Depth of gravel in trench 12" minimum 11. Pi' ends capped h. PUMP OR DOSE SYSTEMS 1. Size of pwip chamber 2. Overflow tank 3. Alarm, visual /audio 4. Pum p easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed by Health Department estimated flow per cycle HOUSE a. House located per approved plans. b. Number of bedrooms WELL a. Well located as per approved plans b. Distance from SDS area measured ft. c. Casing 18" above grade. d. Surface drainage around well acceptable. OVERALL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All pipes flush with inside of box d. Backfill material contains stones < 4" in diameter e. Curtain drain installed according to lan f. Curtain drain outfall protected & dir.to exist.watercours . g. Footing drains discharge away from SDS area h. Surface water rotection adequate i. Errosion contr o rovided on slopes greater than 15 %. Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -3203 Director: Albert H. Padovani M. T. (ASCP) . r A. D. A. HOME BLDRS. 6 MCKINLEY PLACE ARDSLEY,, NY. 10502 L :J LABORATORY REPORT ON THE QUALITY OF WATER LAB # Date Taken• • 8 /29 /88Time• 11:45am Date Rc'd:- Time: m PPR 'Date Reported: 1988 Collected By: Referred By:, Sample Location: Outside hise Cushman Rd. Patterson Y . Phone # b97,.b4O9 Phone # Sample Type: Repeat Test? _ I (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 GENERAL BACTERIA Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform _ Fecal Streptococcus METALS (mg /L) MOST PROBABLE NUMBER TECHNIQUE Copper _ Iron _ Lead Manganese Mercury Sodium Zinc MISCELLANEOUS pH (units) Color (units) Odor (TON) Turbidity (NTU) Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY CFU = Colony Forming Units N/A = Not Applicable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive �( Potable Non- potable STP INF STP EFF Other: Sample Status: (check each) Outgoing HNO3 _ HC1 H2SO4 NaOH ZnOAc Na2S203 Other: Incoming LE 4 °C GT 4°C _ pH LE 2 pH GE 9 pH GE 12 _ Other: REMARKS /COMMENTS (For Lab Use) NLAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO T E NE YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE E OF COLLECT THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA DRINKING WATER CODES, FOR,, ii_E f1 � ARA ERS TESTED, AT THE TIME OF COLLECTION. Bl 2 /86(Rvsd7 /87)RWE �M COQ. -j O WbLL L;Ur'1rLL11UD1 r%Lrvml DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET AOORESS: TOWNIVILL7117ciff- TAX GRID NUMSE8: Cws,ymA.�/v- PA7TERSDn/ .WELL OWNER NAME: A d A C�/.pyj� ,QGc cQci ADDRESS: pgIVATE . c o 0 PUBLIC ZRESIOENTIAL O PURL C SUPPLY AIR /COND. /HER PUMP ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION 0 OTHER (specify) O INDUSTRIAL O INSTITUTIONAL 0 STAND -BY 0 USE OF WELL 1 - primary 2.- secondary MOUNT OF USE YIELD SOUGHT _ L.. gpm. /N0. PEOPLE SERVED :L/ EST. OF DAILY USAGE _T gal. REASON FOR DRILLING 'I,TNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 0?0 S ft. STATIC WATER LEVEL 17 ft. DATE MEASURED aa2 DRILLING EQUIPMENT O ROTARY ($'COMPRESSED AIR PERCUSSION 0 DUG 0 WELL POINT O CABLE PERCUSSION. O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING.. ,;OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH E fL MATERIALS: STEEL O PLASTIC ❑OTHER LENGTH.BELOW GRADE / ft. JOINTS: 0 WELDED THREADED ❑ OTHER DIAMETER in. SEAL: VICEMENT GROUT 0 BENTONITE OOTHER WEIGHT PER FOOT lb./ft. I DRIVESHOE:PYES ONO UNER:0YES 0 SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ❑ NO HOURS SECOND GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE; . DIAMETER OF PACK in. TOP DEPTH ........ft. BOTTOM DEPTH _ H. WELL YIELD TEST If detailed pumping METHOD: O PUMPED a tests were done is in- COMPRESSED AIR formation attached? O SAILeD 0 OTHER I O YES 0 NO 'WELL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE Water ear. ing Well Di". peter FORMATION DESCRIPTION coot, It. IL WELL DEPTH It. DURATION hr. min. DRAWOOWN ft, YIELD gpm. 5 rlace 4,11- 67S of S,4�i/ 02o S /-SS s /as ias- gAC- 7V,e.F WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL. -- PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME Id t��� DATE -T AO RESS SIGs . . 02 V PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - �j,�, 1,Lwk e--4 i . -tal-c� S#A cL./ L r Owner or Purchaser of Building e. D A 4,04AL 'Qul -b tw-S �� t- Building Constructed by -cis � m n . jw4Q Location - Street �r't��sb,✓ #-),,,4, 1 2 Municipality Building Type 11 1 7.2. Section Block Lot buLV!A Sr,RZWi.SrT.,) SS b ivision Name 2- Z Subdivision Lot # GUARANTEE 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 o pirating 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 caised 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 Deaartment of Health as to whether or not the failure of the system to operate was eatsed by the willful or negligent act of the occupant of the building utilizing the system. t1 Datai3 this -1 day of k)6%-1 19 9 b Signature Title .$£1,7- J2 /�,X- Contr ctor (Owner) - Signature�,(� J9ory�20�JS 1) q / Corporation Name (if Corp.) ?1'!� . if0�'1£, Du /LDr-j �NC-- 45 oration Name*(if Corp.) Address i - 1 es /f,� Y f0SZ z rer. 9/85 1 PUTNAM COUNTY= DEPA�tTMEP > - `� DlvlBlon of Envlronmeata! HedtlP rvl CaIrmel N Y 10511 g� r Provide En ee to Permk A CERTIFICATE OF COMP _ :1 peimit r V ��k,�f ..'.. 11 y CONSTRUCTION PERMFf EWAGE DISPOSAL SYSTEM• \ l r } Town erg `ILi S(I else Z Z 1 l 1 Lot . Z Sabdlvlslon Name Sabel "Lot N Ted Map Block �. O .• �,O� -t ZLl t \- Renewal_ ❑ Revision p ,.Owner /AppllcanfName. ��Ot�%lfl�(IC.lC,' tilQr<7 Date of Previoae Approval MaWng.AddreaeSQ MG 1/_11.(lYZ -?aC Town P'nS rr Z1p `lO.JSo�. w tLE.S\tDECL"Il>c 81 'ocv 5 F Building Type Lot Area FIII Sectloa Only ,Depth '� Volame . Number of Bedrooms Design Flow G P D -� PCHD Notlflcitldn Is Regahed When FN Is completed Sepvate Sewerage Syetens to coutilet o['Gallon Sepik T.ank and (o�Z Te be coneteuetea bye �E ` mil- ti.l�t i _ 'Address , WalterSuPPIJ' Public Supply From B Address or: 'Private Supply Drilled by2'l (� t�- Address •, Other Renalrements .- t: ,. " . , ` - ;:. ` . ; ,.; • ::. 'r ,; 1 represent that -t am wft011y anC completely responsible for tho design a'nd locat�oh 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 "regula,ions o.'. a ,._.0 nam . •- - actory.to the Commissional of Healthw�ll County Ospertment ot'- HMlth,.: and ths. Completion thereof a ,, . 1. },caI a t- f ConstrueLOn ComDlunce' saGsf ba_wbmitted to the Department; 'and s written - ,guarantee will :be furnished',he,owner, his wccessors,.haiisor sssigns:by­the builder, Yhat- siid,builder'vG�ll `I place - in good, operating: "condition any part of. -saiC sewage - disposal; system uring the' period of two (2) yea rs.imniediately follow! the datq of tha,istu - once •of the approval of the Certificate •;of Construction_, Compliance of the rigmal syitern or any repbi s there ; 2) th Me.drilled' well descr�DeG.sbove will be . _ -, -3 .11 , iocated.as shown on the approved plan and that` said well'wlll De °ins al eel in accordance th - standards ules d r a Toni of -.the _ Putnam County Department off kealth -- ✓/ S-77 -.� Cam; -I' a `:S�gned R A _. L. ense No APPROVED FOR CONSTR.UCTIO,N Thlsapproval expuestwoyear lromthe aM'iss ed unlessconstruetion of he building bas been undertaken and Is revocable` for -cause oi;' y be ain d C- ormoditied when co'ns�dere cesser by a ommission FI 1 .. Any change or alteration of. construction - requires a new permit p ro or d' posal of tlomestic sane re e, sn r p ' sto p nty: 1�/W Date ev E Title ,7 } �s. APPENDIX B PU111AM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL 9UNTER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT A0/f �f (Name of Owner) lcmm IVTS LF trench provided required 60 ft. max. Parellel to 10 new DATE BY: (Street Location) YES LNO DOCLZ1EN TS Permit Application' Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth 100 yr. flood elev. I 1 I I s/s SUBDIVISION Perc -2-1-30 (3) Fill cd — House Plops - 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) Sewage System Hydraulic Profile - Gravity Flow -Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder 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;shawn;gravity flow,suff. size If PmVed Pit & D Box Shown & Detailed .4 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. 4 110; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL 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 may, Street Address D Town illage City Tax Grid Nu ber WELL OWNER Name kQ� Mailing Address- 1050Z_ 1 - "C r PL, OTrivate 0Public USE OF WELL 1 - primary 2- secondary —�. /�. UYRESIDENTIAL 0 BUSINESS 0 INDUSTRIAL OPUBLIC SUPPLY OAIR /COND /HEAT PUMP O FARM 0 TEST /OBSERVATION U INSTITUTIONAL 0 STAND -BY 13ABANDONED 0 OTHER (specify, 0 AMOUNT OF USE YIELD SOUGHT %j gpm /# PEOPLE SERVEDZr /EST. OF DAILY USAGE al REASON FOR DRILLING ITNEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED .REASON FOR DRILLING WELL TYPE 1315RILLED DRIVEN E]DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 'iii .L L j6;Z: ,jyi.5l�ltl` ! Lot No. WATER WELL CONTRACTOR: Name —�b_ -ze: ..(1NjEin Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES No NAME OF PUBLIC WATER SUPPLY: kA14 TOWN /VIL /CIT'Y DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED' ON REAR OF THIS APPLICATION ZI EPA E S �= 7-6-7 (date) (sin ture 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 s.hall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Rutnam County Health Department attached to this permit. 3. Submit a Well C mpletion Report on a form provided by th Putnam Cou ty Health Depart t. Date of Issue: J 19 1 Id", A Date of Expiration: _ 19 , it Isstrfn§ Official Permit is Non - Transferrable 2/87 White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner Oranae cove: Well Driller 4 Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT. APPLICATION SUBMITTED TO - PUTNAM COUNTY }[EALTH DEPARTMENT. Tb: Commissioner of Health - In the matter of application for ` ev I► _ _ �/'QiL _ - - - - - _ .. , represent that'I am an officer or employee of the corporation( and arts authorized to act for (n -- nw'ame of corporation) _ having offices at -i -t e-,JLr d__-, - �__ (1�b' ✓ Whose• officers a e President _ -- ame an Addr' ss) '- • Vice - President C�2_vt Q- �1 (Na me a ddress){ ' Secretary � - - - - - (Name and Address) . Treasurer -� --------------------------- . (Name• and Address) and that I am ano will be individually responsible for.any or all, actp of the corporation with•respect to the approval requested and all•sub- - sequeA. aeta relating • thereto.' Sworn to before me this t �i. day Signed _ aLclfl ,? - _ _ pp ,,_A� of d 198' Title _V_u e-.P�:1_ Notary Public Lit-; ` Corporate. Seal { _ pUTNM COUNTY DEPAR'.INiW OF HEALTH DIVISION OF. HEALTH SERVICES 4a :.;DESIGN DATA SHEET- SUSSUFACE SEWAGE DISPOSAL SYSTE4 FILE NO. Owner % Sir t tic �c�f/ t� -IA�e� Address C: Located at (Street) QC-C-) Sec. i Block Lot Z.z (indicate nearest cross street) Municipality `�d'i''(C(L- Sc�i�! Watershed Cr-c�r-rp I SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of pre- Soaking q gCo Date of Percolation Test q —Z�—f — &(o HOLE =� NUMBER CfACR TIME PERCOLATION PERCOLATION _ Run Elapse Depth to Water Fran Water.I I _ �- No. Time Ground Surface In Inches Soil Rate :- Start -Stop Min. Start Stop Drop In Min /In Drop Inches inches Inches - /1 150 — 3 : c? } :1 C� 24 Z7 ZQ 2 3:01 - A: 1(c : 311:1`1- 5'.3-7 1 4 9 5 /i Z`7 I 27:46, -3'50 1 •call 3 - 4.50 1;06 .zQ 3 ZZ 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. =� 5 f� 2 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. �-s.a i .� Ywf��`t�.TEST -' PIT. ~DATA . i2DQUIRED, .T0 •BE ,'.SUBMITTID - 'WI'I'fi�APPISCFITION ,,• a }L i� �,. � t4 f ,. , Y�,� � 2 a" ["j ' }�5,�* 71, ., :.:,.- .+,• DESCRIPTION OF n#` wASy.'N+O. !- I LS ENCOUNTERED IN T, E f ST A �SfSOLi L ES <. HOLE N0. HOLE . N0: ' Y,E,y r: .GL 21 31 6' 71 81 91, - 10, 11' .. .... .12' ., 131 14' .......:.- INDICATE LEVEL AT WHICH GROUNIXRATER . IS .ENCOUNTERED V�-i o t�-lC INDICATE LEVEL TO WHICH WATER .LEVEL RISES AFTER BEING ENCOUNTERED�_� DEEP HOLE OBSERVATIONS MADE BY: .tit/ l- Autz�T DATE: DESIGN Soil Rate Used Z( -32b Min /lit Drop: S.D. Usable Area Provided SpOO No. of Bedrooms 4 Septic Tank Capacity 1250 gals. Type Cc'>jcze-j�-,- Absorption Area Provided By &-7Z- L.F. x 24" width trench Other Nate L,UZ0.L - i►. i NC. ,&SSOOJ. j �s. ?C Signature Address F�,,tzneLn zjVE SEAL r� W kly cz -s� No. 56124 F THIS SPACE FOR USE BY HEALTH DEPARTMENr ONLY: OFESSION Soil Rate Approved sq.ft /gal. Checked by Date PIPE sa ° /FT. > STONE N>;L II.ET � Tw0 sipE 6E KK06KED 2WN . G,RAPe 77, ALA, OuT1.ET5 AT SAME ELEV Tp A5- OUil. -T DIM6N510N CHART 6 N- A P� I C, +0 5.1.O' t 9-t.0 11(.0 2 70.0' 5 5.0 15 °98.0' I ( I .0' 3 la. 5' 5a. 5' 1& 102.5' 111.5' 4 83.0' 5.8.5' 17 10 &.5' 112.5 5 89.5' Co I.0' I b I I I •O' 113.5 Co 95.5' &3 - 0' 15 1 1 5. 0' 115.0 7 93.0 110-0 2 0 I R' 1. 5' I &l. O' 8 57.0' 110.0 21 144.0' I GT 0' 9 10 1.5' 110.5' 22 146-5, 1 &7.0' 10 105.5' 1 I 1 . 5' 23 151-0, I o,6.0' 11 1 10. 0' 112.5 24 153.0 1 &L3. O' 12 IIq.5' 114.0' 25 15&,5 1&5 O 13 S"7.0' 112.0 r. L L�