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00521
16
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00521
County''Department . tht ncomptlon thereof a Ct��ca te of C of Health, and 't r
be submitted to the Department, and'a.written guarantee -'will be furnished the .' r,
place in good; operating condition any - part of said sewage disposal system du g f
"ance. of, the approval. -o7 .they Ce►tificate -of 'Construction _compliance of the or final
will be located as shownon the approved plan and that said well will be installed i acc r a
.County 'Department of Health
x
Oates— Signed „
Address'
•APPROVED.FOR.CONSTRUCTION This approval - expires one year from t ' dat R
revocable for cause, or,. may be amended.or moddied when n red necessary b th
jt
requires =a new., Arm
it ApproSod for disposal of dome io san ary s age'' dd /o��L
bate' ^`. "B
_ y vt�
Rev 9 -91- BE EF' N
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tisfactory,to the- Commissioner of Healthwill
`c utceisgn , 0, assigns by the builder; that said builder, will .
ri
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immediately, follow irg_thedate of theAssw
^o;
t er 2) that the drilled .well described. above.
6 i
r rmes' and rdgu aarrpns .' of the Putnam
License No. '
u
of the building has been undertaken and is'. . 1.
issioner °�Ith�
h: Any change at ion of construction
only . c. '
'..
�
•
Title
NOT
ING CONSTRUCTION SUPERVISION- \�
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Address ?t+F sr�S� Town
THE! IT ! 41N - NOT
RVISION _.
Tel eplione.
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PUTNAM COUNTY DEPARTMENT OF HEALTH
bIVISION...OF.ENVIRONMENTAL HEALTH SERVICES .,
COUNTY%OFFICE BUILDING, CARMEL,.N. Y. 10512
DESIGN DATA.SHEET- SEPARATE SEWAGE.DISPOSAL SYSTEM FILE NO-:-
Owne r �17 t�.� Addre s s - e � :�,
Located at (,Street � .ku, /6/r Sec. Block
indicate ' neares cross s ree
Municipality Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS ..;._.
-RoIe
Number CLOCK TIME PERCOLATION
PERCOLATION ;
Run Elapse Depth-to Water a er.. Ve.
No. Time From Ground Surface in Inches
Soil Rate-.,,
Start -Stop Min. Start Stop Drop in --
Min. /in drop
Inches Inches Inches
2 / G �j �1Lts� `,2"
tJ
5
5
A,'AJ A'
Notes: 1) Tests to be repeated at same de lti 1y equal soil
rates are obtained at each percolation to o be submitted
for review. rHt �.Tk F '
2) Depth measurements to be made from top
THE ARCHITECT OR ENGINEER WILL NOT
BE PROVIDING CONSTRUCTION SUPERVISION
DEPTH
G.L.
6"
12"
18"
24°
30"..
36"
42"
4811
5411
60"
66
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOIIB ENCOUNTERED. IN TEST .HOLES .
HOLE NO. HOLE NO. HOLE NO:.
72"
781
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO W11ICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY 2 Date
DESIGN",
Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity " Gals. Type
Absorption Area Prided By L. F.x24" * <;. '37 " width trench.
—� Other
Name SIgnature
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by Date
IN
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