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Home My WebLink About2918DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.15 -1 -57 BOX 24 rum rm . . 16 or 113 1 �, , � ly, , rl y. FM AI . L�L. IS' - i -17`7 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 10512 CERTIFICATE OF CONSTRUCTION-COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM - Town or .Village Located at O'SCq(A,.1'q IyA L,4 e (_:�— /L,40 Owner Me- yE % 6-0 C- 0 STG / A./ Separate Sewerage System built by C AIWIS C u2 S C14A1 Art/ Consisting of Gal. Septic Tank Other requirements t__1Z Water Supply: V11- Public Supply From Private Supply Drilled By Section Block Lot / / Job Address f �i T /S<� V 4' C Lt:�- y— lineal Feet .X Address Building Type >'C �'4 62_' No. of Bedrooms Date Permit Issued Has Erosion Control Been Completed? width trench I certify that the system(s), as listed serving the above premises were constructed essentially as shown on the plans of the completed work (copies of which are attached), and in accordance with the standards, rules and regulations, plans filed, and a permit issued by, the Putnam County Department of Health. Date � / � Certified by � P.E. � R.A. Address 3 0j ,(Q License No. 11%z;J� J_0 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 sewerage system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water 9ply becomes available. Such approvals are subject to modification or change when, in the judgment of the Commissioner of Health, such rev ti modification or change is necessary. Date ey Title PUTNAM COUNTY` DEPARTMENT OF HEALTH Division & Environmenial Hedlih oarvic&,-, Cam,; CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM 7c�TI�OIt�. �- Town or Vi11, e Located at 0 S C_,4 I{JA VN 0 0, i A 4e- 12-13 A D Subdivision aUe'" gkfz- G- AP_ - ")e "S Owner (' �4'; 'e —d1 C, Ic SVPi Q� Building Type.`"` Lot Area �✓� �0� Number of Bedrooms Separate Sewerage System to consist of �=7C\ S i t tot Gal. Septic Tank To be constructed by C tA(?.i S C LLI? 5 C-401A Ilk- v-,. ,, q Water Supply: Public Supply From &�`� KAat- Private Supply to be drilled by Section Block Lot 11 Job Address�� =Q Total Habitable Space Square Feet llaeet�f- s-� lineal l feet X width trench Address T ✓l q[k Address Other, Requirements _Iq A145W ?i'lS f1-PGA Ar-` 612 1 represent that I 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 standards, rules an regulations o e u nam County Department of Health, and that on completion thereof a "Certificate of Construction Comoliance" satisfactory to the Commissioner of Health will be submitted to the Department, and a written guarantee will be furnished the owner, his successors,, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years immediately following thedate of the issu- ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2)'that the drilled well described above will be located as shown on the approved plan and that said well will be installed i iccordance with the standards, rules and regulations of the Putnam County Department of Health. l x - / �-2 ,/ Date Signed PE. _,-- R.A. Address &L Al C'TIOA 4 ` 44- &keL License No.3'�f�f� APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction of the building has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Cgxifmissioner of Health. Any change or alteration of construction - __ ..___,,..ea s... a :.„naafi of ,inmestic sanitarv,sawaae. and /or riva a water supply only. In-, SITE PHONE 9 �5�jo�S� MAILING ADDRESS \cam» e- -- , PERSON INTERVIEWID PCHD Complaint # & Relationship (i.e, ,tenant, etc.) DATE 1A T YPE FACILITY 4a, PROPOSED IdT Ar&a1L1fV PHONE Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. Proposal approved Proposal Disapproved Inspector's Signature & Title with the tions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE FIBS: V&te (PAD); YeUcw (Ttkin BI); Pink GAqli®nt) DATE ADLEY CHADWICK, CONTRACTOR Rt. G & Barger Street SHRUB OAK NEW YORK 10588 A -D D 37; so S7� q Z � S5k 3/ 0 Phone 245.7681 Total Livable Area - $ 10.00 Sanitary Date Zoning Board Approval Estimated Cost $ — $ Plumbing - - - - -$ — ._._.....___..._Well.._.. If Corporation, give title FEE. 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