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02921
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02921
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental . Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Town or Village
_ Located, at
Subdivision—
Owner
Building Type 0Y6 1 I
Number of Bedrooms
Section Block
Lot w Job ,...' ° -A-_
Address S CAVJ A'#3 A ?Q,
1201 NAVY, VAck_e�j
_ 9Total Habitable Space , Z� Square Feet
Separate Sewerage System to consist of �!�C1 J% / Septic Tank lineal feet X width trench
To be constructed by Addresss I
Water Supply: � Public.Supply From G Q ! `%T '��' �!G p'
Private Supply to be drilled by
Address
Other Requirements .
,4
I 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 standards, rules and regulations oT t e . u nam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
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 the date 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 in accordance with the stands ds, rules and regulati— o—' ns of the Putnam
County Department f Hea h,
Date / igned
- U ` i
Address License No,
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless co -on of the building has been undertaken and is
revocable for .cause or may be amended or modified when considered necessary by the Commissio of H Ith. Any change or alteration of construction
requires a new permit. Approved for disposal of domestic sans se , vate only.
Date �` i G By— d Title
IF I
PUTNAM COUNTY DEPARTMENT OF HEALTH
... __.�jtsjgjn.� - nf.. rvly/ Flrcjmanf3y.. Hea% f._:�Fi. ✓;C2c,.iCiar/19ef�_iV:. ___ _ _(
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM ?UT NOAWv- V A1. L q
Town or Village
Locate
Owner
Separate Sewerage System built by �,v �A Q ft A(-J
Consisting o Kt% 1k 94rz Septic Tank e7djS°l '
Water Supply
Other requirements aL Y
--k 'Public Supply From
Section Block
Lot . Job e yy��� y
Address ?U Y ASK` OCUL_el • ./ ' d
lineal Feet X. width trench
Private Supply Drilled By
Address
Building Type �e V v 41 j O ►�+ No. 'of Bedrooms Date Permit Issued
Has Erosion Control Been Completed?
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 a d the permit issued by /,he Putnam I unty Department of Health.
Date h Certified y� -� R.A.
Address L L License
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 waters ecomes available. Such approvals are
subject to modification or change when, in the judgment of the Corn of Health, such re tion, mod 'cation or change is necessary.
Date By Title
am'S NAME
ITE L=TION
PM PUNAM CTY 17NV HEALTH FAX N0. 19142787921 P, 1
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. . _ ....... _ . IE�U�ci�if►i "t:C7UtY�Y rir.��t�i' � iJBFt�t�T� . .... _ y .. ^.. _ .. .... -- . -
DIVISION Or MMRMIM*AL HEATH SERVICES
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PlICNE .4`.Z i F- Z0593
zQt 'y 8
A ING ADDRESS je� i`�/�q !�l EG G � � /Y L/ l o•� ;�,9 -
MSON imERvmE m PCED Cai ilti nt #
Name & Aelationship U.0, owner tenant, etc.)
!ATE l!> 9d 'TYPE FACILITY
QED INSTALLER � �' c %r e d-�1�< Pxon 5s = 1;;KF/I
EGISTRATION # Je C ,
Msal (include sketch locating all adjacent wells):
=.- Repair must be in same location and of same type as original sewage disposal system.
Lfferent location may require submittal of proposal from licensed professional engineer or
!kgietered archItiact.
.oposal approved Proposal Disapproved
Inspector's Signature & Title Date - - --
i
.-opos approved with the following conditions:
. Procurement of any Town permit, if applicaEIe.
:. 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 caaponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. "Installer's' name and number.
(e.g. house corners).
three prwast 6' diem. x 61 deep
. System repair to be performed in accordance with the above proposal and conditions.
as clan or reported a en f owner agree to the above conditions.
G �Z'U�tE ` TI`Y'LE G'� Can X�a //
ems"
OWNER'S NAME
SITE LOCATION
ADDRESS Q 07 )2,a,, '� A k4 o
INTERVIEWED � � Y\ a h/ PCHD Camplaint �
Name & Relationship U.e, owner ®tenant, etc.)
�, X, I A (n TYPE FACILITY
PROPOSED INSTALLER ('A N A
REGISTRATION # L
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original
Different location may require submittal of proposal fram licensed
registered architect.
&
Proposal Disapproved
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Subnission of as built repair sketch in duplicate showing:
a. owner's name.
b. Site Street Name, Town and Tax Asap number.
•
sewage disposal system.
professional engineer or
A
c. Location of installed camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6° diam. x 6e 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 owner agree to the above conditions.
SIGNATURE TITLE D 1^1'f\ �1y DATE NO )0
Imo: Tithe (PAID); Ye]loo (Tarn ffi)e Pink (kli,®nt)
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CART OF C 0 L _'T _L U_,,
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a a J.-La Stet, -- I S Pu�nam COL;``? -VT ;_Je�o e
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OCT- 9796 WED 3:3.38 PM' PUNAM CTY ENV HEALTH PAX N0, 19142787921 P. 1
a PUIW 0170 M HEALTH DEPARU -Mn
k k DIVISION OF MV1RONb4f' *AL HEALTH SEMCFS
PROPOSAL FOR S3W=E DISPOSAL SYSTEM REPAIR
tM I S NAME ii i ., f� -��' PHm ✓E"2 � "' „Za �.3
TE 10MTI0N -9' —dog �4/ J'it! 6zd&-14. lQt
SL= ADDRESS A,' l ° .S'7
RSD`t INTmRviEVED PM c iivlaint #
C�/ & Pz1ationship (.e, cwner,tenant, etc. )
M to /2z / (� TYPE FACILITY
h
�POe
INSTAL' �z z!L OL y ��'•4/� � / c fr C a�t/� PHONE%!y -z5.s = rK�
,GISTRATION # Je
- oposal -(include sketch locating all adjacent wells) :
ms: Repair must be in same location and of same type. as original smmge disposal system.
.fferent location may rewire submittal of proposal from licensed professional engineer or
gistered architect.
w I
,oposal approved Proposal Disapproved
Inspector's Signature & Title Date
i
•opos1 approved with the following conditions:
. Procurement of any Town permit, if applicab e.
:. Submission of as built repair sketch in duplicate shoeing:
a. owner's name.
b. Site Street Nam, Town and Tax Map number.
c. Iccation of installed carponents tied to two fixed points (e.g.,house oorflers).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 5' diam. x b' deep
drywelis surrounded by one foot +• gravel). «
e. 'installer's name and number'.
System repair to be performed in accordance with the above proposal and conditions.
as caner, or report agent of Omer agree to the above conditions. q
GNATURE TITLE ® W/ E/' DATE /Of (O `
M: w1ite (MV);- YSUCW (fin BI); Pink (P}alimnt)
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