HomeMy WebLinkAbout1646DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34.13 -1 -59
BOX 15
NIL-
re `� ■�
is
16 INN 0 4 I I
IN I a.
01646
"CERTIFICATE :-,-.'(�F W
rLOCated at —r=
OWnbr Mrs:
SdiSaiaW'Seweraqe ,S.y em rl
Piho' requiris
p Y.
�0
Bud i g Typez name f
4"0
Has Eroswn rBeen
I.c 'drtify�,ihat 6� - 1,systifn(4, a
attached) an in Ac;orpnc
.:Any -,.,Person ,,o6cUpying prerr
c6ndiflo xesu afin - q.- - rom s
lo,
bate��
955 Y
-P,U- TNAM
soon of En—vj
,COMPL AAF
I
P
4
F,
7
MkST--�'�JOF, HEALTH �tft
k'
rbnmehMV,He;§1th'�'SeMces raiol;.
ICE- ,'F SEWAGLE,,'D,4i6 AL --SYSTEM
Town
section B lock
,j
pFt SION
PRE NTH trench lineal;
P:
seepage
j
stun
./v
',Addi'essL
es; served -,tii ihej above ,iyste
usage.-. ,, ppr4?yaj.pi-,6
sq
h0inie', when, -Ain: the., -judgme
e .,- 1 -0, rn Three �, . ., . � . 1: w - I .
No of Bdroos,,-� Date 'Per
at
t
�ihowh�' f the 'co completed 43-i-
"XR9 �dl esse9tia"y' as wPrk, (copies of wWch,are
;hand the permit ,Issued ' y he Department of -Health-.
R
nii No.
W�, Y, Lice-
I` N e - ' �a .29206
S� maybe "e" r'Y"ji) sei�ure.theL
rol ake such action as -n necessary correction o any unsanitary
,P,O ly4t,
I e..,:,sewerage � iiyii&,,iha4l become 1 1 null ,and ,,void as soon as,,.a public sanit,ary.,rwer, becornes,
me null and, void ,when a �c ; qqoi"mI e - s '
Such .approvals a- r
e
' =,difI cation or- 'change ch anq !s�,nqcessary.
Title'
ve-
"CERTIFICATE :-,-.'(�F W
rLOCated at —r=
OWnbr Mrs:
SdiSaiaW'Seweraqe ,S.y em rl
Piho' requiris
p Y.
�0
Bud i g Typez name f
4"0
Has Eroswn rBeen
I.c 'drtify�,ihat 6� - 1,systifn(4, a
attached) an in Ac;orpnc
.:Any -,.,Person ,,o6cUpying prerr
c6ndiflo xesu afin - q.- - rom s
lo,
bate��
955 Y
-P,U- TNAM
soon of En—vj
,COMPL AAF
I
P
4
F,
7
MkST--�'�JOF, HEALTH �tft
k'
rbnmehMV,He;§1th'�'SeMces raiol;.
ICE- ,'F SEWAGLE,,'D,4i6 AL --SYSTEM
Town
section B lock
,j
pFt SION
PRE NTH trench lineal;
P:
seepage
j
stun
./v
',Addi'essL
es; served -,tii ihej above ,iyste
usage.-. ,, ppr4?yaj.pi-,6
sq
h0inie', when, -Ain: the., -judgme
e .,- 1 -0, rn Three �, . ., . � . 1: w - I .
No of Bdroos,,-� Date 'Per
at
t
�ihowh�' f the 'co completed 43-i-
"XR9 �dl esse9tia"y' as wPrk, (copies of wWch,are
;hand the permit ,Issued ' y he Department of -Health-.
R
nii No.
W�, Y, Lice-
I` N e - ' �a .29206
S� maybe "e" r'Y"ji) sei�ure.theL
rol ake such action as -n necessary correction o any unsanitary
,P,O ly4t,
I e..,:,sewerage � iiyii&,,iha4l become 1 1 null ,and ,,void as soon as,,.a public sanit,ary.,rwer, becornes,
me null and, void ,when a �c ; qqoi"mI e - s '
Such .approvals a- r
e
' =,difI cation or- 'change ch anq !s�,nqcessary.
Title'
',Addi'essL
es; served -,tii ihej above ,iyste
usage.-. ,, ppr4?yaj.pi-,6
sq
h0inie', when, -Ain: the., -judgme
e .,- 1 -0, rn Three �, . ., . � . 1: w - I .
No of Bdroos,,-� Date 'Per
at
t
�ihowh�' f the 'co completed 43-i-
"XR9 �dl esse9tia"y' as wPrk, (copies of wWch,are
;hand the permit ,Issued ' y he Department of -Health-.
R
nii No.
W�, Y, Lice-
I` N e - ' �a .29206
S� maybe "e" r'Y"ji) sei�ure.theL
rol ake such action as -n necessary correction o any unsanitary
,P,O ly4t,
I e..,:,sewerage � iiyii&,,iha4l become 1 1 null ,and ,,void as soon as,,.a public sanit,ary.,rwer, becornes,
me null and, void ,when a �c ; qqoi"mI e - s '
Such .approvals a- r
e
' =,difI cation or- 'change ch anq !s�,nqcessary.
Title'
-^z.- w
P '
i
Q.ai,1i1ER O.R, i URCHASER OF BUILDING
BUILDIN CONSTRUCTED BY
LOCATION — STREET
r(GL_Inn P
BUILDING TYPE
14UNIC IPALITY
TIC �W In
BLOCK
`13
LOT
GUARANTY OF SEPARATE STtIAGE SYSTEM
I represent that I am wholly and completely responsible for the
location, workmanship, material, construction and drainage of the sewage.
disposal aystem 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 of two years immediately following the date of completion of
the sewage disposal system, or any repairs made by me to such system,
except where the failure to operate properly is caused by the wilful
or negligent act of the occupant of the building utilizing the system.
The undersigned further .agrees to accept as conclusive the. deter - - ._-
`-mination'Yo-f - the airactor-- of °the Division -of Environmental HeaZth--Servi.ces--
of the Putnam County Department of Health.as to whether or not the failure
of the system to operate was caused by the wilful or negligent act of
the occupant of the building utilizing the system.
Dated this o9,4 day of 19_IL
at ��dA -
PLACE & STATE
c
Signature
Title
CORPORATION, GIVE NAME &
ADDRESS)
GUARANTOR IS REQUIRED TO FILE NOTICE OF .DATE OF FIRST. USE OF
SYSTEM.
Division of Environmental Health Services, Putnam County Department of
Health
i
4P7
41-
8
8
i
o, 00'1, �tti - 'a"1V'JCa ,-
L L w xvi- ,A� -��.
' sa•�-, nod
/ AVNSS -3 ?may
//i� / /•cjcra� ^e�� 'sue _ ,
'n 1
. � '"� �� k., e��°t•.�t�"�d Wiz;••,
t x
41,
s