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HomeMy WebLinkAbout0326DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 13. -2 -25 BOX 4 I,yL y ` '� r lid 1 < : 1 00135 DEPAR T NE i OF IMALTH D iv1rion of Ens irnnmental Health Services 6 Genava Road Brewster, 1Vaw York 10509 Tal. (914) 278.6130 Fax (9I4) 278 - 7921 STREETI ,dw N,AIVM-Z14'Md4, f PHONE PCHD r BRUCE R FOLLY Public Hecirh Dir:c!cr IN A2M ADDRESS / AZljl ��— /1/�____ . tiLtiiBER OF EkISTING BEI3ROOlNISS PROPOSED # CF BEDROONISJ�A (QOM CERT. OF 000iJFANC —C 0 CERTIFICATIO:s FROM SUILOLNG r- .sPECTOR) *.Any addition «hich is cons dared a bedroom requires formal approval ofpIau (Construction Permit) prepa<Pd by a P-rcfessioral Winc, veer or Registered Architect in accordance with aoplicab ',e sections of tI:e Pumarn County Sarita.*y Code. Please submit this fc:z: Ward th:- fo'IoINing to Putnam Couary Health Dcpt., 4 Geneva Rd., Brewster, NY 10509, Phcae 27S -6130. 1. Certified check or money order for 5100.00 Sketches of existing floor p;an (drawn to scale, all living area including basement) " Non-professional skeins. are acceptable 3. Two sets of proposed floor plan (drawn to Scare, with name, street, and t.a ., r:_ap T} * No i- p.ofessiorlai sketches are acceptable 4. Copy of suvcy sh.owin; we11 and septic location, to the best of your knowledge. Incitlde date of installation if kr-o,.Vn: Label all wells and septic systems within 200 feet of the property lire. Contact his office wi-1 any questions. 5. Copy of Cert. of Occupancy frcm Town or Certif cati= fras Building Dept. Nith leali bedroom court of dwelling. C;ommea s =:b 93 N I0.2'i.'o1 " E Z7-i" oo� Mpt•M, G2urrs 4 yAea ;E dvornoH FoIL James I. Nixon, III AIA THOM,&17 4 TI Hd LE-&-f HE•2' ARCHITECTURE and. I P-RK.KHc>UhE Rp, Pd'1fE¢G,oN, HY COMMUNITY DESIGN ITS I'�r�N 23 op¢ .2�2 35 MAIN ST. BREWSTER, NY 10509 845.278.6301 fax 845.278.8461 0 S Nh3* 4 3ci "w� NEW % -flo¢Y 1-7 00' . "Iv &PpllfloN l0 ai o, 'Do, &.11 ` \ - ExIHTInq DEcic I •ya�t' qo.4' E�Y4hkir CD ` I (? ID hIEW ForYEe 0" 1 00 /abolTlbN re.XIhllHfi� 71LI�EWY '' �o ZI l �• E)(14 fq q pILNEw4y oro LD . bQ:IvE6:bY .311 ......•. . NoV'i H ' �G�ITE • :PL�iN hl'(E P,&16 T�v�N FkorM..L,U¢v.EY of 1'2orF-aTlr • I3EINy LOT r-O Ah hNcWrl bN.: /sMf�NbRD:htlaiF�I�.IhICiN I'L -r LcYfh *?,7, 8 f ..7: ©F 6'PAM& - 6U3bIVhi10H 9cc1, I FI�En.:Map�t 23G66 >:ILED MOMCJd 81 Io�l I°I?EI's2EP &-f TEOLY <:ErtySNOC-trF e-OLLIIVy rXTV? JUHE 24,1 1 Mpt•M, G2urrs 4 yAea ;E dvornoH FoIL James I. Nixon, III AIA THOM,&17 4 TI Hd LE-&-f HE•2' ARCHITECTURE and. I P-RK.KHc>UhE Rp, Pd'1fE¢G,oN, HY COMMUNITY DESIGN ITS I'�r�N 23 op¢ .2�2 35 MAIN ST. BREWSTER, NY 10509 845.278.6301 fax 845.278.8461 BRUCE R._FOCEY. Re Acting Puhiie Mealth C�i�.•t.�r DEPARTMENT OF HEALTH Division . Of Environmental Health Services 4 Geneva' Road, .Brewster, Ne%,v York 10509 (914) 278 -6130 - Putnam. County Dept. of H:.ait`:; 4 leneva Road 37ewster, NY 10SC9 �idenc� Tax Map Tom Genucmen: Accoidi.ng to records maintaired by the Tu\�—,t, the above noted dv elfin; iS IS \11QT in cornpiian , v,ith Tov, . code aid the total number of bedrooms on record IS This infoi7 nation lias been obtai.Ied from: CERTIFICATE Or OCCLIPAi�CY: AS3ESS0RS RE-:CORD: U..: HER �Buildin.c- .. LORETTA • MOLINARI R.N., M.S.N. Public Health Director i 'ROBERT 1. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva-Road,' �Brewster,New York 10509 ' : Environmental Health (845) 218.6130 Fax (845) 278 -7921 Nurslag Services .(845) 278:.6558 VAC (845) 278 - 6678 Fax (845) 278.6085 Early InterventionNreschool (84S) 278 .6014 Fax (845) 278 - 6648 ' EACSEAME TRANSMITTAL To' Z� Li t Fax: From: f i�f! Date:.' Dage's CC: ....' ...... .... ... ......................................... ....:.......................... ❑ 'Urgent • ❑ For P eyiew ❑ Please Conuterit Q please Reply ' _ 'CONMIID NTIA= STA' tbMNT: :.The infoimatioa coritained'ia this facsimile may "contain CONFIDENTIAL and legally protected information intended only for the use. of the individual or'entitynamed above: if the reader of this' message is not the inteaded..recipient, yon are hereby notMed that nay dissension, disWbudon, or cop3!ing of this. teleco is* rolubited. If you received this teleco to error, please immediat notify us b ., fete hone Py y p. yo Py �Y, Y (845- 278.6130} and destroy.all documents associated with this facsimile: PAM' M W WAGN DISPOSAL SYS W . ` °• - LgaaMd at q or Vef W it tdtttedalaa Nttoe Lst N I— Tea Map 10 Me& F, tat creaser /Applltabit Nmie Date of Pmwjkm Appfovai s Ors Adieaa X 2 . iow. I—Jpprt� L.) zip 12 3 Tl�to Gills 44 r4c4nn A.nnrnuAd I l ) (j ,99 PAP Frill nCP(i 0 A.........#- M&S roc GYP• ( - Atom � - POr Secfl.. Oab LLTDW& 31 S ► va�.e�'S�� . Nfsstiar 1 Il.i�. p�Desip slow G P D I 71SO PC® NN0eadoa Is Rogvk" Whm Bm 4 em*h ed SPpeaM &wdr*p w ttaaaiee 1 Sop* TW* •-+ Te be eoarhtaMoa.b� 1 " ' J Addraoo WOW Souls Ftesis Adhow on ���+ --d SW* MW M � �!r /cam _ . I1 1 represent that 1 am wholly ano completely responsible for the design and location of the proposed system(s). 1) that the separate saw disposals em above described . will be constructed at shown on the approved amendment there to and in accordance with the standard; rules a rpu ns .1 nam County Department ' of Maealti and that an eompM4loo.thereof a "Certificate of Construction Compliaiand" satisfactory to the Commissioner of Mealthwill be submitted to the Dollars mtent. and a written guarantee will be furnished the owner. his s ccesms. halt or assigns by the ullder, that said builder will place In 'good .opral ft condition any pat of said sewage disposal system during the period of two (2) years ItnmaMlle hewing thedate of the inu- anca of the appronAt of the Certificate of Construction Compliance of the original system or any rapk thr4 2) the h drilled well described above wN be Muted as drosrw on the approved plan and that seal "I will be Instal accordan the ndrds. r egu s of the Putnam County Depart of MMltk. Date !` r � i Signed Addre License No APPROVED FOR CONSTRUCTION: This approval eapkse two years from the date issued unless construction of tgf building has boon undertaken and is revocable-for cause or may be amended or modified when considered neceffKY by the Commissioner of Mglth ny change or alteration of construction reOUMM/a a Permit.. APM-1 for disposal of dgMrik sanitary SOW WO. and/ o wata► sulsty on! x. 10188 l 3 G�� /ex ` .PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. 3 86 Division of Eavirottmental Health Services, Carmel, N:Y.10S12 \ Engineer Mast Provide N CE C OF Located at Owner /applicant Name MaWng Address :G. D •Permit 3E DISPOSAL SYSTEM�SZ��l Towp or Village �--- Ta: Map 3 � Bflocck�, A Lot_ -7 Subdivision Name 0– Subdv. Lot #-9 zpp 7, p� � Date Permit Issued Separate Sewerage System built by Consisting of eO� Gallon Septic Tank and Water Supply: Public Supply From Address on '!P�riv�at —e - Supply Drilled by _ Address g��g TypoJ i 7c� V..l I /i-�i Ha8 Erosion Control Been Completed? - Number of -Bedrooms � Has Garbage Grinder.Been Installed? Other Requirements �7ni`J ' F _!� AL� I certify that the slyetem(s) as.listed serving the above premises were constructed essentially as shown on the Pip fa f the completed work ( copies of which are attached), d_in accordance with the standards, rules and regulati�naccordance with the 1 the permit issued by the Putnam county c4pirtment of l:ea th. Date Certified by P.E. ' R. A. Address loose No..l�! Any parson occupying premises served by the above system(s) shall promptly take such action as may be necessary o n the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewers em shall become hull and void as soon as a pubt'o unitary sewer becomes available and the approval of the private water supply shall become nu a v id vvhe� a pubik: water supply becomes available. Such approvals are subject to' modif ratlopyNor change when, in the judgment, of the C ml ner of Mult h revocation, modification or change Is necessary, Data 1 DY O Title t� +" �X�Ir t•l�wT TTT wr,LL Uvrlr LPG Aviv air vni Office Use Only, a DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH WELL LOCATION STREET AOURESS: WNIVIL ! 1 Y TAX GRIO NUMBER: WELL OWNER ADDRESS: NAME: PRIVATE ❑ PUBLIC USE OF WELL 9RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED 1- primary ❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE S' YIELD SOUGHT' `fi gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE Dgal. REASON FOR NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ��� ft. STATIC WATER LEVEL oar ftj DATE MEASURED ' DRILLING ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE � J ❑ SCREENED O OPEN END CASING. [I OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH L_ ft. MATERIALS: STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE --Q ft. JOINTS: ❑ WELDED THREADED ❑ OTHER CASING DETAILS DIAMETER �- in. SEAL: ❑ CEMENT GROUT BENTONITE ❑OTHER WEIGHT PER FOOT _ Ib. /ft. DRIVE SHOE. K YES ❑ NO I LINER: 0YES $NO SCREEN DIAMETER 'SLOT SIZE LENGTH (ft) DEPTH T REEN (ft) DEVELOPED? IRST YES ❑ NO DETAILS SE D HORS GRAVEL PACK ❑YES GRAVEL DIAMETER TOP Borsht ❑ NO SIZE.. OF PACK in. DEPTH ft. OEM It. WELL YIELD TEST pumping t I( detailed If more detailed formation descriptions or sieve analyses ELL LOG are available. please attach. METHOD: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? PTH FROM URFACE r Water Bear- Well Dla- ❑ 8AILED ❑ OTHER ; O YES ❑ NO Ing (meter FORMATION OESCAIP710N pOE, tL WELL DEPTH DURATION DRAWOOWN YIELD Surface v `' �• ft. hr. min. ft. gpm. WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE _ ��� !� -44C• r ti i 'CAPACITY WEL � DRILLER NAME DATE LBREERT M. HYATT & SONS, INCsIDriTtruRE MAKER DEPTH Well Drilling MODEL VOLTAGE HP Rt6.`311. R.R. 2 Box 171A �� -- 4 PATTERSON, NEW YORK 12563 PUTNAM COUN`T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 9AjzA= Owner or Purchaser of Building Section Block Lot Building Constructed by Iii u ':� T!-:1' � i 1 Location- Street Municipality '- - �N Building Type Subdivision Name 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 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 Environmental 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 day of 41,dA,.A94 Signature C)' Title General Contractor (Owner) - Signature Corporation Name (if Corp.) Corporation Name (if Corp.) Address Address rev. 9/85 mk rY DEPARTMENT OF HEALTH EN'�jIR NMENTAL HEALTH LABORATORY -2f i 4 KET STREET POUGHKEEPSIE, ;NEW "YORK 12601 LAB NO.. FORWARD, REPORT TO: (PLEASE :PRINT) TYPE OF FACILITY E 'DE " F Y..� r :I .l 1^ �S ❑ PUBLIC WATER SUPPLY NAME -r [;:;; IVATE RESIDENCE .STREET.ADDRESS CD WASTEWATER TREATMENT•FACILITY:.. CITY -� + ZI ❑ BEACH. ... . .D ,OTHER: FACILITY :NAME G't js�r , � ��1` ��y l - � � TOWN: :p PHONE _ `0 MONITORING, SAMPLE, SAMPLING "POINT.. O CHECK SAMPLE SOURCE: "1;1,- DRINKINGWATER . - ❑ SURFACE,WATER;- ❑ WASTEWATER; s0 OTHER:. D :FREE "TREATMENT._ ED CHLORINATED "� ' PPM ❑ COMBINED OTHER, r 0 TOTAL p DCHD PERSONNEL COLLECTED BY: F — �' � s .} -i -.1 s� .,i TITLE: --`O NON '.DCHD PERSONNEL I s. DATE SAMPLED' TIME' ICE w AMt0Y "a ; AM YES ` �1 4 a PM ' NO ( r PK4 NO. F 4MFT ❑ MRN TOTAL COLIFORM COUNT % ! PER 100 ML 1 1 ❑ M" FT ❑ MPN FECALCOLIFORM_COUNT PER 100 ML ` r - l E MFT ❑ MPN FECAL STREP. COUNT PER 100 Mt 4 ❑ STANDARD PLATECOUNT PER 1 ML-. �y ❑ misc.} DID. THESE RESULTS INDICATE THAT THE WATER SAMPLE'DID NOT � DRINKING iMEET SATISFACTORY SANITARY QUALITY FOR �;:$WIMMING. - ❑:'WASTEWATER EFFLUENT' WHEN:'THE SAMPLE WAS - -COLLECTED. FOR INFORMATION 'CONCERNING; UNSATISFACTORY.SAMPLES PLEASE; CALLTHEHEALTH DEPARTMENTATz` = T T , SuLTS ,'JNVAGID 7 TY SEAL E AB V �0.101 LAP � f x. y TERIOLOGICAL; S%ANIRAT�IOR ,OF witzR CUSTOMER CQPY LAB_ ;DIRECTbR I N to* 22'Ola E 27oi, x& S- C� Si r 0 S N�i3 °14'3y "W NEW 2 -s1o¢Y 1-7. 00' h10 - -- °22' 0 "W �o.i 2' &;Pql ION ? • r—ato '- y DEcic pDVItION \ \ e voiri; bEUG. Ex MCI 30.1.' 261yEp.�� � 1 �? t`IEW Fcy'fER � 1 c' DO /abD ITION FJ�I�i11N6� 7tLlvEtibY 31� 0 '1 EXIh(INr4 f)fLNEhY�Y ;� ^t . ?o P,E A6pNvoNEh paaaohCn _bQIvEI�Y � S t' -TE H02. -1 /VITE PL&H. hI1E {70 ?4 -rh-um F- otA - hU¢v.EY CF reoPEaT'f F3KiHy LOT V-0 /.h iiNcWH ON iy"IENbED.�i11Fi1�I.iIhIGiN I'L -T LcJih r7,7, 8 f .7 OF I FILEb..Mpl'# 236oD CITED h-i�ItUa 8, IO�I r26Pb2ED $,lf —,E¢21Y 13E2yet4P •2.FF COLLIIVy rXTEP JuNE 24,190J1 17'el2¢M. hun Ej ewjE tupr2 TIOH Fo¢ Tames I. Nixon, III AIA THOMA,47 4TINd I- E-&THEP— ARCHITECTURE and . P�RKkI -IpUhE RD, C'b"IfE¢G,oN� NY COMM UNITYDESIGN. ITE i'��N 23 WwIL 2002 35 MAIN s30 fax 845 27.8461 845.278.6301 'fax 845.276.8461 COINT[tUf:.1'IL bYS� ea.t t '�1 8 RU7ls A \il It „* : : •i .',Ct <� U v� C cY'.illi ALL ORPAMUNrY OF 10- A.iTl. Al 0 Uf (T(f 1 �.b 50- o IzL, r 7i,-j -C CF CT- E�VN M, D (zpr7-L ls =c: s l- - - 5 cm- YES 1 NO CCC-Ly--a' MS pe— I -,cn ccr=crate R--sc;1ut2,.*c:j. Tr1ree Sa�-- imears Au c I c4' Cc I -rT I nct- Ma.; S7- d="t_�l C- losr= aclem cect:l T- E 'H, ........ . C: rc --cn per_ = V-- " C VDEC Ps z D=-.� C-N PL'a-N'Z- z7-- -l-1 — cz -lr D P pit c= = - -= WeL,j r Eer,7-Lcs Li.nls iff ratai Two Fcc-t cz-n-tcurS Ex--Sz-inc & Dr-L-vewav & Sicc Cz-,- C-H, cf: P? t -& D Bcx C, & D' Ecuse - NO. C-f Bed= �TeLlc & E:nc-l= cf W/ & Ecunzls ic t) NC rl-; 4 CTz, N 10 t� ?.L _, T--aes,Tl,-- C-f 201 t-.o-FcumcHz-t--;c-,l iYcl 1 S pj�-= 100, tc 200' D.L.-C-Or 100' t.-- St--Sam, 131 to :,)r--- Fz-- t — S 2. E!) DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL f4W PCHD PERMIT # WELL LOCATION . S reet Address wn Village City Tax Grid ..Number WELL OWNER am Mailing Addr s OF p o`1 2 u aRrivate O Public USE OF WELL 1 - primary 2- secondary -- RE 11 P SIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED 0 OTHER (specify, O AMOUNT OF USE. YIELD -'.SOUGHT S gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 0U(i,g.1 REASON FOR 'DRILLING E] REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION D:'ADDITIONAL SUPPLY B-NEW SUPPLY NEW DWELLING) O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE ILLED DRIVEN ODUG .GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES ENO IF WELL 15 LUCKEED 1N :A KEALTT bUBVIV1b1UN, NAME UY 5Ul5U1V151UN: Lot No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES —'NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH ,& SOURCES OF CONTAMINATION PROVIDED LF��P A RATE SHEET �`j (date) 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. 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 aIm /anner as not to degrade or otherwise- contaminate surface or groundwater. Date of Issue: /�O' G' �% 19 zz 7 Date of Expiration 19 C_ / Permit Issuing Official Permit is Non - Transferrable �-- f— White.copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller ", I PLTIMM COUN'T'Y DEPARTME3r OF HEALTH .- DIVISION OF ENVIRONMERIAL BEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SFWAGE DISPOSAL SYSTEM FILE NO. il • - P Address -pn ¢max Located at (Street) �=2 1 S (indi to nearest cross street) tvO 10 3 Lot Municipality Watershed Date of Pre - Soaking `j (. `� Date of Percolation Test SOLE NUMBER CLOCK 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 0 C30 12 T 2 b-3v S0 1 3 O F11 5 7 10 ^1 30 30 4 4 5 � G�T IC�cJ 1s� 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 frdm top of hole. i rev. 9/85 i TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. % HOLE NO. G.L. t L d7avA 1' '6 P,0 c.li J �U�� ✓'% 2' 3' 1 / 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used 2 Min /1" Drop: S.D. Usable Area Provided QC00 No. of Bedrooms 4" Septic Tank Capacity gals. Type &91%94 Absorption Area Provided By L.F. x 24" width trench Other - �=��. �-� C ss- �, �07F� Signat 0 •�4�'�, // Nme Address THIS SPACE FOR USE BY HEALTH ONLY: Soil Rate Approved • ft/gal. Checked • Date