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Street CP CP Road Inspector Date C CC CC Inspector Date T CORTLAND COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH 60 CENTRAL AVENUE, CORTLAND, NY 13045 PH: (607) 753-5035 FAX: (607) 758-5578 APPLICATION FOR SUBSURFACE SEWAGE TREATMENT PERMIT To the Permit Issuing Officer: Application is hereby made for a Construction Permit to install a private sewage treatment system to serve the hereinafter described property, concerning which the following information is submitted: Owner Phone Mailing Map Property No. Phone or Address Use of Building New Existing……….……..; Lot Size No. Bed Rooms No. Occupants No. Apartment Garbage Disposal Basement Fixtures (including Yes or No Water Supply: Existing Proposed Well Spring Public…………… Date Signature ******HEALTH DEPARTMENT USE ONLY****** Type Minimum Depth Ground Water To Rock Soil Tests – Date of Minutes Deep Hole Depth: Hole # Depth (inches) 1st Run 2nd Run 3rd Run Treatment Rate Gal/S. F. Sewage Flow…………………….Gal/Day Approved for Sub-Surface Treatment For Fill For Sand Filter Disapproved ………………………Conditioned Realty Subdivision Y N Engineering Plan Y N ……………………..Multiple Inspection time Inspector……………………………Date……………. ---PAGE BREAK--- SKETCH AND SPECIFICATIONS BUILDING SEWER 4’ cast iron, or NSF approved DWV schedule 40 or SDR 35 plastic, water tight joints, minimum grade ¼’ per foot, supported to prevent setting. Minimum distance to well 25 ft. SEPTIC TANK Water tight concrete, or Com Std. Metal, UL approved, Capacity ………….gallons; Minimum distance from house …..feet; from water supply, 50 feet. Support on undisturbed ground free of large stones. Washed gravel base is best. SEWER FROM TANK TO TREATMENT AREA DWV Schedule 40 or SDR 35 plastic pipe over disturbed ground. Tight joints; Minimum grade 1/8’ per foot. DISTRIBUTION BOX No. outlets………………..; Outlets all same level and 4’ from bottom; Inlet at least 1’ above outlets. Concrete or approved equivalent. Place on 4” washed stone base, seal outlets with plastic roof cement. Test for proper operation with water. FILL Length Width Depth Use porous fill; Do not use heavy clay soil. Fill must be inspected and allowed to settle 45 days before trenching. Do not strip top soil within 50 feet of fill and in fill area. Provide for diversion of surface water where necessary. LEACHING FIELD 4’ perforated pipe; Total ft. No. laterals Length per Lateral Grade not more than 1/16” per ft.: trench width ……………inches; Depth …………..inches; Minimum distance from water supply Minimum distance between center of trenches of No. 1,2, or 3 washed gravel under pipe and 2” above pipe; Lay building paper or straw over gravel before replacing earth; Do not strip soil, nor work when wet nor run heavy equipment over tile field area. Keep laterals out of driveways and 20 ft from banks, edge of fills, footer drains, waterlines and gaslines. LEACHING PIT Minimum distance from water supply cylindrical; Size inside walls;………………….diameter depth below inlet Walls of concrete block or equivalent with openings facing out; Use 12” No. 2 or 3 gravel around walls; Use concrete cover with minimum 8” inspection hole, or call for inspection before placing cover. An equivalent sized precast leaching pit may be used. SAND FILTER Length Width Depth sand Sand must be from an approved source; Must be inspected before and after placing sand. Provide for diversion of surface water where necessary. REMARKS All pipes must be supported to prevent setting. PLEASE READ BOTH SIDES CAREFULLY – SAVE FOR FUTURE REFERENCE A “Certificate of Completion” will not be issued if the system is not in accordance with the sketch and specifications.