Loading...
HomeMy WebLinkAbout2927DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourd,ocs.com 631- 589 -8100 62.15 -1 -67 BOX 24 , 6 ;�'• wow I L% f ' 02927 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 10512 T .'S 7i:wT .. T 7 1."D Iwr- Ft P QM WAG-;. GC' F T..! C =�. i�i�:i: � ";� .7 r�, :�7 ?�1 C. i i�.f, 1. �. ras:� aSSF�S. >� ��. Town or Village Located at �) o E T` V �- Owner AA rz!�i r Separate Sewerage System built by AA 1E- !�j Consisting of Gal. Septic Tank Other requirements Z fA T M4 •, " Vs ;5 4 Water Supply: i/ Public Supply From Lam_ Private Supply Drilled By Section Block Lot Jobn� Address lineal Feet X width trench )< S +E" JDLEp £ ih711ik.y SJ -G" Dup = 34C 5, , 5 Address ' Building Type iZ E: ).i V kl• t (J 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, and t e permit issued by the Putnam County artment of Health. Date ! j I `I Certified by P. R.A. I �L� Address C�— ti ©'` License No.� cc1�, — • �s 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 supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Commissioner of ealth, such revo odification or change is necessary. . �. �b--- Date By Title Locate Subdiv Owner PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental. Health Services, Carmel, N. YC.. 10512 na :s FOPI n An b==L .SYSTEM. ice+ i +_ JALL" Town or Village Building Type V& K)O V 6:110 Lot Area Number of Bedrooms Separate Sewerage System to consist of E lit Y4_ ) Q C1 R4r Septic Tank Section / Block (� Lot Job Address 0SCANAAMNik L C_ 41) e t )-T n) Am V 4LLL.�4 1� i Total Habitable Space ,` Square Feet lineal feet X To be constructed by D /? Q Address's A i p Water Supply: Public-Supply From �+ lK of Q•,, � Private Supply to be drilled by Other Requirements width trench I 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 and regulations o 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 standards, rules an regulations of the Putnam County Department of Health. Date ( —) Signed P.E. R.A. U Address tL4 �..lA (N: d I ki ; , License No. 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 ommissi er of Health. Any change or alteration of construction requires a new per t. Approved for disposal of domestic ni sewage, a d/o private wajkr supply only.. Date By a Title �` ry ._ .... �,. •.rte .. `R! .,. r PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225- 3838/225- 3833/225 -3641 ` riti��ti)Sr1i, kR SEWAuE -DISPOSAL REP OWNER'S NAME � 10 A P, G( M c ' ) O AJ A � (� PHONE SITE LOCATION 6 G.t t /- MAC GA kV t-fv.S MAILING ADDRESS G 7`'y 4 ltl V,4 11-ex /Lo� 1`• PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER a #Aj 6�, I ems%- PHONE Sd e G Proposal (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 IC A2r� - c' U spectorIs 1T title batel Proposal approved.with the following conditions: 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. as owner, or reported agent of owner agree to the above conditions. ^/ SIGNATURE �"�/ Cti/ °� �^°� TITLE c�mrs►�► . DATE 3 -93 ' X 7 CPM: Hhitie (R'1D); YeUcw (fin 8I); Pink ftplimnt) /I e�l t7 •p 01 ' Z O o� r i F \ S, ,x r4 0 .. ���� --,� _ ..rte � "� -"•-. j; • , is 7-ANF <LINLS Z E PT IC SYSTEt�1 i, MAP N• 1RvI' . SURVEY Sl-rUp,TED 1N pug q lA:'� TOWN SCALE DA`T t 7