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PUTNAM COUN'I1Y DEPARTMENT -'OF HEALTH
Division of Environmental HnIth Services, Carmel, N. Y. 10512 Permit # Y
CERTIFICATE OF CONSTRSUCT16N COMPLIANCE FOR SEWAGE, DISPOSAL SYSTEM S"JO .VL
Town or village
Located �at Tax Map JLT •.'(Q•. Block
Owner / Formerly Tax Map Lot # `— Subd. Lot #
Separate Sewerage System built by Address
Consisting of al. Septic Tank and
Other requirements
Water Supply: Public Supply From
__]C Private Supply Drilled By C�i �TINC� -,a
Address
-IM
Building Type)�a�s I No, of Bedrooms Date Permit Issued
Has Erosion Control Been Completed?
Y
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, in accordance with the file n, and the permit issued by the
Putnam County Department Of Health. '
VC—
Date I Certified by - P. E. R.A.
Address r7 Z License No.ALg�2
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary ytocure the correction of any unsanitary
conditions resulting from such usage.' Approval of the separate sewerage system shall become null and void as a public sanitary sewer becomes
available and the approval of the private water supply shall become I and -void when a pub water pply becomes avalNbla. Such approvals are
subject to modification or. change when, In the judgment of the MI of Health, pfiCh revocatl n, modification or change is necessary.
Date —, By Title
Rev. 9 -81
Owhet or urchas�er cif Building
Building Constructed by
ao� RA P'CV4E k s
Location - Street
VALL
Municipality
Building Type
346
Section
. 3
Lot
Subdivision Name
Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE 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.regu.lations of the Putnam
County Department of Health, and hereby guarantee to the owner, his success -
o,rs, heirs or assigns, to place in good operating condition any part of
said system constructed by me which fails to operate for a period of two
years immediately following the date'of initial use 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 willful or negligent act of the occu-
pant of the building utilizing the system.
The undersigned further agrees. "to accept as conclusive the determin-
_, ration ,of the_- Director- of- tithe Div_ isi_ on of Environmental Health .Servi_ces.
of the Putnam County Department _of Healrth as to whether`or not`the�fai'
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
n
Dated this / / day of 19 9� Signature
Title
Corporation Name if Corp.
1. S A
Address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
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CONSTRUCTION STRjJCTION _.PERMIT :,FOR '.SEWAGE ,'b1S
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_ Town - village
aLx mock__
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Bull in 'T
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u er `bf edrooms.l.
Design il G/ P/D
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Se 'i6rige .Sqjtern to consist of A,
we rage
jo.-be-bonstruc -t ' a by
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-,Water. St , ippiy*..
:;• Public Supply From
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-:771
Prwate Supply to be dii4
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Address'
Other equtrervjep s
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rqp!esqn t th a. am wholly-,Ind completely *,responsib,le,
abo-ve-descri b ad will be constructed as show rt qktoe'a ppr�
'Couinfybepartrnerit' .of !1l841 and
bi,'iubihitted A6 .1" e
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D lace - Do Der atind"
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con 61 iiK-ahv-Dah ,Wia,sAkf!m
aunty Department of Health
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_Health __
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Address
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n 4 des 2n ` proposed ;
, .1 ) th 1 t. t" h e . se para t
a, sewage disposal .riyste
nr i I 6&rdance.wi t h the.s t andarck.4 leCa �reau a� so s o e,,Puxnam
.w
Any change. oi,'a" M
-revocabile-fo "A Iteration o .,constr
requires a° new pamit F•Ap roved f�sposal of domestic dart' s w e .a /or pnvatew supply r icaijid or maybe Rrpmlss 6W..Bf.
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P113 D CTIC;CK LIST.
Date
w �.v .,..:.c ur.: •..•.� -• •...:- ..:...n. ... o -.,-�- .ap. ..:r, -7:: c;oa:•. ai•3 .;ti.ae.-..s.4 i
IN-I.T.TAL SITE INSPEC T TO `
yes.
No
Comments
,Property lines or dorners found : ..
Can estimate house location .. ., .
Will driveway need cut o . . . . . . .
Must, trees be removed -note these
-
Is deep hole representative of entire SDS area
Additional deep holes needed...
Sufficlent SDS area*. available considering
--
driveway cut, house location, separation ,
distances, etc.
DEEP • HOLE DATA
Depth:
Water elevation:
Rock elevation:
Soils descri.Dt i on:
Date . 10- L .
--
FIX-AL SI7TE IN 1P ECTIGN Insp . by:
Hou s- located where 'shoi,n on approved. plan
SDS _located where approved . ..
_ --
.'lerz.th of -trench measur -ed
- --
W i.dth of trench average
Slope of the line and trench.acceptable
_
loom _al3:owed- •for -e�
fiver 6 f;. from swan p,lrate'r` "course
Natural soil not.stripped or SDS area
-
ivariecessarily graded .. .
10. rt. maintained from prop line and.
-
20 ft. from house .
Sep-"-ration of .trench from house.,. well
'-
-- etc.- follows--plan :---- :- __,__- ;-- ;�--- ,---- ,_- _o�_ - -- -------- .__- - - - - --
-- -� - - --
_
- - - - --
-- ------ - - - - -- - - - - -= -.. - - --
htunber of bedrooims checks
Stone's., brush..' stlu: ps, rubble, etc-, greater
than 15 ft. from nearest trench
15 PL.. of peripheral soil horizontally from
_
trench. . • . . . . . . . .
Junction boles properly set
Coi -O.d surface run off from driveway, roads,
C)x )c g
• ground surface ., . etc. clhanniel near SDS , . ,
area. . . . . . . . . . . . . . . .
Dae:s 7.ot. drain" I re a.pp_aj, 0. K. J.n area of SDS
-
FI.NAL GRhDING OF SITE ACCEPT -AM-B
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