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BOX 7
00561
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00561
Rev. 3/ 86 PUTNAM COUNTY DEPARTMENT OF HEALTH
.v
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Mast Provide g
P.C'A.D. Permit N
CERTIFICATE CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM YP7 TT Sh A
or v e
Located at (/1 nG 1s "'s /� 1 VG _ /�Ta: Map BI9fk Lot
Owner /applicant Name " / /y `!'%%llTI2� erly lJ6V1GL� �iPA� � �GIn - l
abd)viston Name - cSabdv rLot N p�
Mailing Addrea�t i i�co LL &t7- fy/ T�Lip I Date Permit Issued !n %• �( �' %U � / )
Ap es
Separate Sewerage System built by �� " IC" / .S &--5Z C 17 V 11 T /DA) Address DO x
Consisting of /000 Gallon Septic Tank and P06 L
Water Supply: Public Supply From Address
or: v Private Supply Drilled by�cnoe -r %�i • !7`��17 ��
/�
,, 1P
Building Type 20s / -P&7- {T / el-- Has Erosion Control Been Completed?
Number of Bedrooms 'J Has Garbage Grinder Been Installed?
Other Requirements
2 certify that the system(s) as listed serving the above premises were constructed as ntia11 as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rul an r lation accordance with the filed plan, and the permit issued by the
Putnam tyDDeOp�artment(Of Health. //
Date 111ky
e �,T'L P.E. R.A.
Address T i7 �/� I G c�i/ (F� : �1T / ! +r d • " /" IA5 me No. L / ;X
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewers stem shall become null and void as won as a pubC... sanitary awn becomes
available and the approval of the private water supply shall become n and old when a p blic water supply becomes available. Such approvals are
subject to /mods ication or change when, in the judgment of the omm r of It h revoutlon, modification or change Is nnooIIFaJs/ /�'XJ
Oats �` BY TIt10
0
�t
. PUTNAM COUN N DEPARTMEW OF HEALTV
DIVISION OF ENVIRONMENTAL HEALTH SERVIGU
I e-%j Ma (LY
Owner or Purchaser of Building
N EJ-4, fc-5 It y \U6(Z �.0 - o
Building Constructed by
SaMEIZSc-
Location - Street
16�
I
P,
Section Block Lot
i�URN w A
Subdivision Name
Municipality Subdivision Lot #
Co10A/^i - ( - C0S40M rQ -At-re
Building Type
GUARA= 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 Environirental 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 utilizi g
the system. --I-
Dated this 5 day of � 19 �?
74, I�Re
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
4*-? W 65-1 01c) f ti6RM W)m
Address
rev. 9/85
mk
Signature
Title
Corporation Name (if Corp.)
k,)v /la 00y,<X
Address
yl
s
HEALTH DEPT
WELL COMPLETION REPORT
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT 07 HEALTH
Office Use
DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (It)
SCREEN
DETAILS FIRST
SECOND
GRAVEL PACK ❑ YES GRAVEL
❑ NO SIZE:
WELL YIELD TEST
MVH00: ❑ PUMPED
fll COMPRESSED AIR
❑ 8AILED ❑ OTHER
WELL DEPTH DURATION
It. hr. min.
-92#v 1 6
If detailed pumping
t tests were done is in-
formation attached?
❑ YES O NO
ORAWDOWN YIELD
It. I gpm.
WATER VCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ❑ NO
ANALYSIS ATTACHED? ❑ YES ❑ NO
PUMP INFORMATION
TYPE S a 6 M fC 1'51 9 /C CAPACITY -10
MAKER ('a ,U iU D 5 DEPTH go()
MODEL S7_, VOLTAGE!2�UHP 1'.�_
DIAMETER
OF PACK _
WELL LOG acre av
TOP
in. DEPTH
tailed formation di
ble. Dlease attach.
DEVELOPED?
❑ YES ❑ NO
HOURS
BOTTOM
_ ft. DEPTH It.
or sieve analyses
DEPTH FROM
SURFACE
STREET ADDRESS:
To NIVILLA / 1 Y TAX GRID NUMBER:
WELL LOCATION
3i 3i' Z Ii 7�4
-WELL.OWNER
NAME:
ADDRESS:
Al, /A
PRIVATE
❑ PUBLIC
ec
r-
Set t?
USE OF WELL
RESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS
❑ FARM O TEST /OBSERVATION O OTHER (specify)
2 - secondary
O INDUSTRIAL
O INSTITUTIONAL ❑ STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT
gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 1�(- gal.
REASON FOR
9NEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
❑ REPLACE EXISTING
SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA
WELL.DEPTH
�� ft.
STATIC WATER LEVEL�ft.
DATE MEASURED �F
DRILLING
❑ ROTARY
COMPRESSED AIR PERCUSSION ❑DUG
EQUIPMENT
O WELL POINT
❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED
��
❑ OPEN END CASING. d OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH
a/ fL
MATERIALS: STEEL ❑ PLASTIC O OTHER
LENGTH .BELOW GRADEC. ft.
JOINTS: ❑ WELDED 9THREADED . ❑ OTHER
CASING
DIAMETER
6 in.
SEAL: ❑ CEMENT GROUT WBENTONITE POTHER
DETAILS
WEIGHT PER FOOT /Z Ib /ft
DRIVE SHOE YES ❑ NO
I LINER: ❑ YES eNO
DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (It)
SCREEN
DETAILS FIRST
SECOND
GRAVEL PACK ❑ YES GRAVEL
❑ NO SIZE:
WELL YIELD TEST
MVH00: ❑ PUMPED
fll COMPRESSED AIR
❑ 8AILED ❑ OTHER
WELL DEPTH DURATION
It. hr. min.
-92#v 1 6
If detailed pumping
t tests were done is in-
formation attached?
❑ YES O NO
ORAWDOWN YIELD
It. I gpm.
WATER VCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ❑ NO
ANALYSIS ATTACHED? ❑ YES ❑ NO
PUMP INFORMATION
TYPE S a 6 M fC 1'51 9 /C CAPACITY -10
MAKER ('a ,U iU D 5 DEPTH go()
MODEL S7_, VOLTAGE!2�UHP 1'.�_
DIAMETER
OF PACK _
WELL LOG acre av
TOP
in. DEPTH
tailed formation di
ble. Dlease attach.
DEVELOPED?
❑ YES ❑ NO
HOURS
BOTTOM
_ ft. DEPTH It.
or sieve analyses
DEPTH FROM
SURFACE
Water
Bear-
Ong
Well
Dia-
Ineter
FORMATION DESCRIPTION
CODE.
Land
Surface
Set t?
V
6
�
C ln 5 !O
STORAGE TANK: TYPEk..7bO °�. �.•
CAPACITY Q1AwbPkvN Z06^4 i. GAL. OD
WELL DRILLER NAME DATE
M. HYATT &SONS, INC.,,..:
Well Drilling
Rte. 3 1 R.R. 2 B,pa� 171A 1,2563
FINP.L SITE IN ?EC?'ION
STRErr LLyC�TION G Gii! w� �/ /2 , ' �� „� CWNR.R _
P.�,TRM?T ff TIM a OR SUBDIVISION LOT a 3
I-
II
IV.
a
VI.
Bate
Inspated by
YES NO
SE-.GE DISPOSAL AREA
a. SDS area located as per approved plans
--
b.
Fill section - Date of placement
2.1 barrier_ LGTH W -= AVG_DPTH
c.
Natural soil not s tr ivoed
•--I
d.
Stone, brush, etc_, greater than 15' from SDS are?.
I I
e_,
100 ft. from water course /wetlands.
DISPOSP.L SYSTEM
a. Septic tank size 1,250
a-�--
b.
Septic tank instal -led level
I I
c.
10' minimum fren foundation
I
d.
No 90° be-rids, cleanout within 10 ft. of 45° bend
I I
e.
DISTRIBUTION BOX
1. All outlets at same elevation - water tested
( I
2. Protects below frost
I ( I
3. Minim= 2 ft. oriciral soil betrie--h box and trenches
I i
f.
JUNCTION BOX - vroperly set
I (
g.
TRENCEFS
1. Len reau: Te*3 - 3 `j LZ*lq`` -h instal-led
I
2. Distance to watercourse ne sured : f"
3. Installed ac— ording to plan
wr I
4. Distance centre" to ce_nte_r
5. Slore of tench acceptable 1/16 - 1/32 " /foot.
L-99
6. 10 feet =ran prone_--ty line - 20 feet - foun- 5atiors
I I 7
7. Demth or t= e_-ici < 30 inches from ssrface
8. Roam allaw --ed for es•Larsion, 50%
I /1 I
9. Size of cruel 3/4 - 1j" diameter
I I
10. Depth of cravel in tre.*lch 12" mini= 1
111. Pipe ends pured
h.
-.! OR DOSE SYSTEMS
1. Size of mrm cha.r-L -r
2. Overflow tank
3. Alain, visual/audio
1 1
4. Pump easilv accessible manhole to araae
5. First box haf-Ied
I
6. Cvcle witnessed by Hez-11th Dena_ I
I
I
estimated flaw r c- ,role I
BC�t /�/o f /.� `/-
a. House located per approved plans. di
•
b.
Number of bedroers c (
-.0
a. Well located as r-e-- a =roved plans
b.
Distance free SDS area mcrsured
c.
Casing 18" above Qrade.
I
d.
Surface d_*- a*_nac_ e around well acceptable. I
1
a. Boxes prod arouted
b.
?.il ipes part.ia11v bac filled I
c.
ALL pipes flu--h with inside of box
d.
Bar -kfill material cont=ains stones < 4" in diameter
0.
e.
Curtain drain installed according to plan
f.
Curtain drain cutfall prote -tea & dir.to exist.watercoursd
g.
Footing drains disc =ce away free SDS area
0, I
h.
Surface water protection adeouate
i.
erosion C nzro"l provided on slopes Greater than 15 %.
PUTNAM COUN DEPARTMENT OF HEALTH
TY
Dlvlelso of I+itivkom ®ante! Haslt6 Sam4ces. Carmel. N.Yo i l? - CERTMICATE � 'Permit M
-` MW
CpNSTBUCglON PERMIT FOR SEWAGE,DISPOSAL SYSTLIbi : rper+>ut M7 F -Ci L • - "'
Located at" �.tM . ��. S -e • ✓ _ own tle-Y� ..'
S.bdlyldlon Name�O B al.uia 1 C� ubd: Lot x TaY. S idek
eneaiel O - Revlebn ,..
Date" of Prevbne Approval
MalUn& Address Town Zip
Jul
Rye Type Loy Aga i.3..
%Z i9e
selo® enc Only Dept TVolnme
Nnmbor of Bedroom - _2 " Design Flow.G P D � PCHD Nottatloo Is Regat -4 FOl le completed
Sarate Seaeme System to ooetaw of on Soptic Tank"en�1 3� 6 ` •
ep
To. be eooshdcted by 1 C7 0 70 INf l VJ P Address
Wster,SuPPb: Pool: Supply From ' _ Addreas
or: Prlvnte,Sup* Delllod by
Otboe Reaatcemilt.
1 represent thatl am wholly and cOmplstaly rosponfible for tha tlefign::dnd location Of the proposed systems) 1)' that the separate saiv&" ispoYlsystem
above described will beeonstri cted as shown On, sere apDrovedsmendmant there to.and in accordance with the itanda►ds rules an _ regq a_�ons o 0; u nom
County "Oepartmant of Flealth;'and this on completion th!reot a'-'Certiflcate of Constiuctlon Compliance" satisfactory to. 6a Commissioner. of Healthwill
be `.submitted to the DepartmehC, and.: :a` written quarantee -will be furnished'the owner, his succpaors. hairs or assigns by. the buildN,ihatsaid builder will
pteca:in good operating. condition; any part of fold sewage disposal` system "during thi period of two (2) Years ImtnediitNy folbwirig thedits of the iisu-
anee; or'thq .approval bt tear Csrt.fiuts of, Construction'Complia he original syitem.,w any repairs thsret 2) strut the drilled.well;tle_sc/ibed ' fbove
will be 7oated "as shown on the approvotl plan antl that said welllwill a Ins all in are " ante with the st arts r les and regu a ens of the Putnam
CountyMOepartmert of` llealthp
oae.:1 Y gCbl'�k�- j ,. I. si9 f/
Aporess / /` P)
APPROVEO'POR CONSTRUCTION Thit ppprovalAbitp:res ; two:y
revocabl6 for cause or`may"tie amended .or "lnodlfied'Wherl,COnsidt
requires aw °pormd ':A ro�nvicetl for dispofal oYdomesticfan
Rev. A:% O� / • . -.
1/87 Date / _ BY
ti
P. RR..A.
r ✓ �✓ Y -License No v
om the date issued unless construction of the building has _:been, undertaken and is
c nary 'by they Commissioner Of Health. Any change or alteration of construction
ge, Drivate�wwaatt�er supply only.
itle
I
r Putn :. �.nty Department "of.}Iealt
Division of Environmental' Sanitation
Secretary _ t l _
(Name and Address)
Treasurer
'- .(Name and Address)
and that I= amand will be individually responsible for, any or all acto
t of. the- corporation with respect to the approval requested and•all -sub-
Sequent acts relating thereto.
Sworn to before me this day Signed _ - ^ _�►_^
of v 1 198S Title _[{• _ _ _ ^ _
Public' Notary
�w; ldr�c
Corporate Seal
•- AFFIDAVIT - CORPORATE . OWNER APPLICATION
FOR PERMIT. APPLICATION SUBMITTED-TO
PUTNAM COUNTY HEALTH DEPARTMENT
! :
TO: Commissioner of Health - In the matter of application for` '
?^D V3 a s
...
I, N�Gk�2S --- ...
=_`- represent,
_W/•i�N� _A_ -------
that.I am an officer or employee of the corporation
and am;authoriied'
to act .__0edes _ u�w'p_s ____
-=-- --
•for- _?1VG,
(name of corporation)
--
'
having offices at _ �p� (i _ blc3 -tic'&'± g0 _
4
w�i�_ �'�•_ `,
Whose officers are
President _ _�_ �4�ivE" -� _ NEG �eS - ! >o� �4 _
9P-2A2m RD, - WWwF(l1��.
(Name and Address).
Vice - President TA�ME� eOK
. (Name and Address)
Secretary _ t l _
(Name and Address)
Treasurer
'- .(Name and Address)
and that I= amand will be individually responsible for, any or all acto
t of. the- corporation with respect to the approval requested and•all -sub-
Sequent acts relating thereto.
Sworn to before me this day Signed _ - ^ _�►_^
of v 1 198S Title _[{• _ _ _ ^ _
Public' Notary
�w; ldr�c
Corporate Seal
wn
�
Dais
� APPROVED FOR-CONSTI
Date
' — ----------
n
id builder. will
te of the'. issu-
)n of the building . has been undertaken and is
I!P. Any change or alteration of construction
Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL �% o
PCHD PERMIT # /D
WELL LOCATION
Street Address
0A45IM5ET DtZIVIE5
65
Town/ Tax Grid Number
6nl - !v (31")
WELL OWNER
Name Mailing
EV4L AE-5`!2_ 6iA I V17evrz' LC
Address 04,+4 0Private
-D F PP.WM_,11"r70 Public
USE OF WELL
® - primary
2- secondary
RESIDENTIAL
O BUSINESS
El INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP P ❑ ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
NEW SUPPLY
O REPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
i DCiTI v
TP�L(G
WELL TYPE
®DRILLED
aDRIVEN
DDUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
e_ O" W Pr!-L. Lot No.
WATER WELL CONTRACTOR:
Name -ro
65
1>07T120 1MeD
Address:
DISTANCE TO PROPERTY
FROM NEAREST WATER MAIN:
IS PUBLIC WATER SUPPLY
AVAILABLE
TO
SITE:
YES X NO
NAME OF PUBLIC WATER
SUPPLY: /R
TOWN /VIL /CITY
DISTANCE TO PROPERTY
FROM NEAREST WATER MAIN:
v�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION 00 SEP TE
(date) (signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as s.et 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 provi d by he Pu. am County
Health Depar ment.
Date of Issue: ✓� '� 19
Date of Expiration: 2 2 19 Pkfmit Issuing OffIcial
Permit is Non- Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
APPE`EDLC B
PriMMAI.1 CCIJNT" DEP FMA r OF E E-a-MH - D177ISICI OF E-1• IVTt CrY—E7NTML DE 'A.LH S-JVICS
R[Drill MML WZ TZR SJPPLI & SuBSiRF =— Sr`T..vi?C DISPC'SM SiST 4-c
(iIcTF' Of C.- -nar)
REJT ' ,.rte = T - CONS==ICN P—r =T
BY: r
(S - LIC.X is =)
DCCI�Y. —=
Pe�Y;li= P��1 i cr.ticn
C--rr..crat✓ Re- =oluticn
Plans - ThrF�e
E":GZnC -°•-YJ AL`LZCrZZ-t_'_cn
Desirl Data- Sheet (DDS)
Desc Eci _ L,--,c
CcrsiSt =n t Pe Yc R=-s i -S (3 )
PsYc Hble Dect-i
HC'`s_ Plans - Two SC =_
Weil
CE =fir.
L, 1_ Sa E c::v_sicn
SUtD1gY�S1C:7
CG
SSiS P-"- Lct= C =_
We _a ^ M7,� /DEC Ps =,i = R & i
Da_ Ca OCS plans & psrmi ` Sc:_
REQ = D =,c CN P:_�tiS
- .va a Svs a-n Plan - ( rt -h. a=_z'%)
Fill 1 �F_of' -i e & DL' =_rS_cns - V:;_- _
D Or J Ecx;__= ZC: /C=_1=
S: C T�n:c
tiVe_'- 1 Derma_ l , Service Lii:c if CT• c_
CCnSt_"LCt'_C.n Notes (Crindar rat=)
Ees_cn Data: perc curia die —o
Two -:root Con`C.urs F {i cti nC & P -c-cS=
Dri vewav & SICCes Cut
FcaL��e�C- `aL_er,C „-=min Drains CK)
Perc & Deen Ecles Lccaz
Repres, -mr- .L2. ve cr
{_c1 =1Cn P?'c ;Sl1Cw�i;�rcvit_i f_C`ti,�af=. Sie
If P,--mDed Pit & D Box Sacwn & Cetmil
ECU=e - No. Cf BerrCCmus
Wells & SSDS' s w /in 200 ft- c= r cpose^ S_vst-
P,ocertn' i _c5 & Bcunds
Hcu_,-- Sct^ac'.i Necessary (TiCZt ict)
Heusi Seier - 1 /4„/ t. a "0; JZ-= pipe
NO Ec�AS; 'Ma:{. Eer: - a]' w /C_:._. --ut-
SZP _RPSIC''N DISZ°' =-S L'`T-n CN PT - :Vj
Fields
10' to P.L., Drive'iav, T_ es,TCp cf
20' to F=ry ticn Walls
100' to We-11; 200' in D.L.O.D, 150' pi`s
100' to Stream, WazeY ur.e, La,<- (L.-IC. eX
15' to Ora *'ns Car`.in, Leader, FcotinG
35'to c tC =: �cS1n,S�crrnrC?n,�l"= -1 ryct�Y::
10' to �itt =r Line (pit= -20' )
50' 2Ilt�YP LtL�*!t arm? P =Qe C"'"5=
SeOt'.0 `I`cnks
10' f_cn F cundticn; 50' to
15' Well to PL
_
rwai _ -z D
60 ft.
L-1-3
1005,- e
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10 L_
=i11 rAlt= e
I
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1:0 vr. f el ev. I
i
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r= ser-voi , e-
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1�
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HC'`s_ Plans - Two SC =_
Weil
CE =fir.
L, 1_ Sa E c::v_sicn
SUtD1gY�S1C:7
CG
SSiS P-"- Lct= C =_
We _a ^ M7,� /DEC Ps =,i = R & i
Da_ Ca OCS plans & psrmi ` Sc:_
REQ = D =,c CN P:_�tiS
- .va a Svs a-n Plan - ( rt -h. a=_z'%)
Fill 1 �F_of' -i e & DL' =_rS_cns - V:;_- _
D Or J Ecx;__= ZC: /C=_1=
S: C T�n:c
tiVe_'- 1 Derma_ l , Service Lii:c if CT• c_
CCnSt_"LCt'_C.n Notes (Crindar rat=)
Ees_cn Data: perc curia die —o
Two -:root Con`C.urs F {i cti nC & P -c-cS=
Dri vewav & SICCes Cut
FcaL��e�C- `aL_er,C „-=min Drains CK)
Perc & Deen Ecles Lccaz
Repres, -mr- .L2. ve cr
{_c1 =1Cn P?'c ;Sl1Cw�i;�rcvit_i f_C`ti,�af=. Sie
If P,--mDed Pit & D Box Sacwn & Cetmil
ECU=e - No. Cf BerrCCmus
Wells & SSDS' s w /in 200 ft- c= r cpose^ S_vst-
P,ocertn' i _c5 & Bcunds
Hcu_,-- Sct^ac'.i Necessary (TiCZt ict)
Heusi Seier - 1 /4„/ t. a "0; JZ-= pipe
NO Ec�AS; 'Ma:{. Eer: - a]' w /C_:._. --ut-
SZP _RPSIC''N DISZ°' =-S L'`T-n CN PT - :Vj
Fields
10' to P.L., Drive'iav, T_ es,TCp cf
20' to F=ry ticn Walls
100' to We-11; 200' in D.L.O.D, 150' pi`s
100' to Stream, WazeY ur.e, La,<- (L.-IC. eX
15' to Ora *'ns Car`.in, Leader, FcotinG
35'to c tC =: �cS1n,S�crrnrC?n,�l"= -1 ryct�Y::
10' to �itt =r Line (pit= -20' )
50' 2Ilt�YP LtL�*!t arm? P =Qe C"'"5=
SeOt'.0 `I`cnks
10' f_cn F cundticn; 50' to
15' Well to PL
AM •XDEPARTMENT;.
iOF' HEALTH
• r • U• •N Ks v FMALTH-SERVICES
DESIGN DATA SHEET- SUBSUFACE SAGE DISPOSA SYSTEM - FILE NO.
OLb FA-i2M
Owner N ads U ij DEj &S- fSG Addres JGT. .N `f / 2 33
Located, at "(Street&M6,�f-T �29'' DeW Sec. 1 Block Lot
(indicate nearest cross street)
Municipality Watershe3 C9,0 role/
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking 5 Date of Percolation Test
HOLE
NCF= C= 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
12: 4.7 -7 Z2 25 -3 �
2 !244 - I 22 21 rl-
C 3 12: �- 1.03 22 2�
- - -- - - --
4
GN
P� 2 4r:5
4
5
1
r.
2V2
30 22
Z�j 22
25
3"
2 ✓ 3'�
-3"
A
Id
NOTES: 1. Tests to be repeated at same depth until apprcoci.mately 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
Name {�A_- NDOL,PN- ...1�. - f�l c izt lT Signa
Address 7 �?) Dpa (U(-:51 SEAL
IN d
pig 7 7 0-��OM) AlY
i
®� ES'
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft %gal. Checked by Date ,
}PIT.'L1ATA`:RDQUIRF,D TO.'= BE >SUBMITTED. ;WITH .APPLICATION
." , - DESCRIPTION ; OF -' SOIIS :.'ENCOUNTERED
::IN TEST ' HOLES
DEPTH HOLE: NO HOLE: NO
HOLE ,NO.'
r 1
G L
r;
2'
7.
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDGQATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL • RISES AFTER BEING ENCOUNTERED .....NO N o. ....
DEEP HOLE OBSERVATIONS MADE BY:
DATE: 8?
DESIGN
Soil Rate Used iO Min /1" Drop: D. 9 p
S.D. Usable. Area Provided
No. of Bedroans ?J Septic Tank Capacity AQQ gals. Type 6�'l jam,
Absorption Area Provided By �J�6a L.F. x
24" width trench_
Other Other
p NEW'
e)_
Name {�A_- NDOL,PN- ...1�. - f�l c izt lT Signa
Address 7 �?) Dpa (U(-:51 SEAL
IN d
pig 7 7 0-��OM) AlY
i
®� ES'
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft %gal. Checked by Date ,
/• \ WELL — \(�►�o)
--
��p
L 591 .O
r?OL I r7
Z-1571?119-TIO OOOGAI� P'f--(P TANK I
5G L.P. AVO. / ' JUNGX ON
oll
i
� V
d / 6 •
1 _
j NOTE: LINE ANP TOPO-
/ GIe,APHIGAL 1.NP0(eMA ?(ON TAKEN
10KOM 1:�,tA DN15tON PLAT f;N -
TIT(ZD " Sf�GTION TWO - GOKNWAU-
KIPOE "' 'ILEP MAP NO. 2117A.
A� - O.0 l L,-T
G,OALe •. 1 " +0'
A5 VUIL7
nIMENyION CHAR-(
N °
A
p>
Col -10
6
B.1 -0„
-P2 -0
i2
- PZ'-O.
THIy I,!�i TO or_KTfF -f THAT THr, SeN
OIM019AL �Y�if✓M W�� GONSTI2UG�
INVIGA-M,t? ON THIS fl AN.I ANi? THE
WAS lN�t' GTrt,? i3`f Mr, I3Zr -age, IT
GONI JZI✓P AU9-12. lHL SY� -f�M WAS
✓TICI)GTEt? IN AGGOIP:NGF IN ITH A
STANt�Ai2t� lZULE� �, 12'�GULf?iTIONS G
I°UTNAM COUNT; OF H
ANn 1H>✓ NeN YOIeK ✓TATC, L- 26t'AR -1
l9—r ` H.0 -ALTH
NOTE'• HOVye 4 IN.eLL- L.OGATION '"(A
�IeOM IuKvrll. OF rKorll1 _ `f " I'KIv
�OI� NGKLE� VUILI�U��S ING•, f7A,
10-�O -8q, p'��PAIeE1� P�'f I�UNNEYf
GIATI✓5i L •g