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441, FF H A�
Rev. 3186 t ADivlsfoaofEnvironmeWYHed Se ces,OCarmel,N I<QS)
....
Engineer Must Provide
3?- P.C.H.D. Permit #
CERTIFICATE OF CONSTRUCTION- COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Town or Village
Located at Ta= Map t Block — Lot
i.
Owner/applicant Name S? • Formerly SAC `' <:t$abdivieion Name Lot #
Mailing Address SU41:t5'T. 16.= 40 ZIP Date Peruilt issued
n.3 J
rt Ll Io *klpJ ► V $ 1
Separate S4werage System built by "�" - gj: N k- Address SAME
. i AS Afio V a
Consisting of % Gallon Septic Tank and --3 3
Water Supply: Public Supply From 1 Address
or:— Private Supply Drilled by Wes, Address.
'
Building Tyie Orj14CA1Z Has Erosion Control Been Completed? 1�'
I
,t
Number of Has Garbage Grinder Been.lnstalled?
--
Other Regt 6ments
I certify that the system(s) as listed serving ,the above premises were construct as nt' ly a sh
on.the; plans of'the "completed work (.copies
of which are attached), and,in accordance with the standards, rules and regula
Putnam County Department O H lyi�.�
the filed plan, and the permiZissue y the
-
Date i Certified by
K7,
PE.
f
Address112'/4�L
t.icense No.J u
Any person 'occupying premises served by the above systems) shall promptly take such actlon as. may be ntdsury to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewer go system shall become null and void as soon *as a pubtt: unitary sewer becomes
available and the approval of the private .water supply shall become nu d Jo when a' lati ter wDply
beto availabN. Such approvals are
subject to m ifirat n or change when, in the judgment of the C Issto t of M su evoutio mddifl tlon or ehan!p s
J7
nemunry.
Date `� r KY .
tY
Titb'
8
PUTNAM COUNTY DEPARTMENT OF HEALTH
-. DIVISION..OF ENVIRO1NMENAL HEALTH SERVICES
�u�d �►Iye� Charles k�SS�er �q �. li����_.._
Owner or Purchaser of Building Section Block Lot
(- R COQ 4 vu-ilo
Building Constructed by
�z I ,e.
Location - Street Subdivision NarAJ
Municipality Subdivision Lot #
1l�CIn
Building Type
GUARANIM 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 fora 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 Environinental 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 19ffk
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature
Title
Corporation Name (if Corp.)
Address
' ENGINEER TO PROVIDE PERMIT #
PUTNAM CO 1VT. -:DEPARTMENT .OF HEALTH ON CERT FIC OF C MP N E.
. ' Division of Environment ii . Health- Services, Carmel, N. Y. 10512.1 PERMIT
CONSTRUCTI PERMIT FOR SEWAGE DISPOSAL SYSTEM
Tow or Village
C� �/✓'J� �¢�J ti y� yJ
Located at,*", �V Ile i�O(t"a- ira�a.� .d �QTT250N Tax Map f Flock �7`�T lot /�/ t 1
Subdivision �'�(ot%I— LIFO ,•l gsTla�': ES Subd. Lot 9 _ Renewal .—CI Revision r •.�
Owner /Addrer,s � - Date of Previous Approval - -- -
Building Type Lot Area ` p'r Fill Section only ❑
Number of'Bedrooms Design Flow G /P /D� P.C. H. D. Notification R ired
Separate SQwerage.System to consists. of de.i�...91r:. CGayi . &el ic� a f} 'm
To be constructed by "` Address .
Water Supply: Public Supply From
,q Private Supply, to be drilled. by
Address
Other Requirements
s .
1 represent that 1 am wholly and completely responsible for the design and location 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 standarps, rules an regulations o e u nam
County Department of Health, and that on completion thereof a "Certificate of Construc'`'tion co hin satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owns h's succ rs, ei s or assigns by the builder, that said builder will .
place in good operating condition any part of said sewage disposal system during rio f tw (2) ears irrjmediately following thedate of'the issu-
ance of the approval of the Certificate of. Construction Compliance of thb on sy m an epairs ereio; 2) that the drilled well described abo
db will be located as shown on the approved plan and that said well will be installed o an wit he stand rds, rules and reguls ons of the P am
County Department of Health.
Date Signed P.E. R.A.
Address License No.
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless Struction of the building has been undertaken and is
revocable for cause or may be amended or ;fled when co 'dared n scary the Commis ner of Health. Any change or stion of construction
requires anew remit. Appr ve to disposal of dome sa itary s age, a /o rivate at 1
i 1(/
Date— R� By ritle
! Rev. 6/85
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