HomeMy WebLinkAboutRiesenfeld ELIZABETH A. NEVILLE,MMC Town Hall, 53095 Main Road
TOWN CLERK � � � P.O. Box 1179
a� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS k �,i� �)IN �� Fax(631)765-6145
MARRIAGE OFFICER „ ti Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ,.
FREEDOM OF INFORMATION OFFICER www•southoldtownny.gov
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED: September 23, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4789 for a Cesspool/Septic Tank Construction
Permit submitted by:
Mark Riesenfeld
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and return it to me. Thank you.
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE e
Comments:
..
Signature
...........
Dated
ELIZABETH A.NEVILLE
Town Hall, 53095 Main Road
Box 1179
TOWN CLERK Southold, New York 11971
REGISTRAR OF VITAL STATISTICS All
MARRIAGE RECORDS MANAGEMENT OFFICE Fax( 1} 765-6145
ICE Telephone (631) 765-1800
FREEDOM F INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ 1 on- esi a tial 5 Application
Permit No.
ApplicantName.. .�� a " �� � �.. .. ..�. . ... _.
Applicant Mailing Address
............
Septic Tank ' _'or....Cesspool—
Brief
ss ool
vj-- Ss 11 "u�.0t7 - ....v
_� ....ww
Brie f i esei ptio�I of Proposed Construction or Alteration
c _ ...�,� ...� �:�. .................._.....
Location of ProposedConstruction/Alteration:
Owner o Property: ......A, ___.. uv..
N 1 ,.0 �
Owner Mailing Ad dress: 6
Owner PropertyAddress:
Name and phone number of contact person
Tax Map No: Section an, Block - � _ ........, Lot w
Cross Street -mm..._ .. . ........... ----
NOTE: LOCATION MAP MUST BE SUBMITTED IT APPLICATION. NEW
CONSTRUCTION QUA S SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Ap:.litc, it: Date
Received -,�. ...... . ..�..
COUNTY OF SUFFOLK
UNOFFICIAL COPY
for price quote purposes only
Reclaim Our Water
STEVEN BELLONE
SUFFOLK COUNTY EXECUTIVE
DEPARTMENT OF HEALTH SERVICES JAMES L.TOMARKEN, MD,MPH,MBA,MSW
Commissioner
P R 1 CON TIN5
Health Services Reference#
The attached'plan, when duly signed by a representative of the Department, in conjunction with these
conditions, constitutes a permit to construct a sewage disposal and/or water supply for the property as
depicted. The applicant should take note of any conditions of approval,which'may be indicated on the plan
or enclosed herein. Construction must be in conformance with the approved plan(s), as well as applicable
standards including"Standards for Approval of Plans and'Construction for Sewage Disposal Systems
for Single Family Residences." Omissions, inconsistencies or lack of detail on the plan do not release the
applicant from the responsibility of ensuring that the construction is performed in conformance with
applicable standards. Issuance of this permit shall in no way relieve the licensed design professional of
responsibility for the adequacy of the complete design.
The permit (plan) expires three (3) years after the approval date. Any modification to the approved design
requires submission of a revised plan and additional fees (if applicable) for reapproval prior to construction.
No inspections will be performed by the Department if a copy of the approved site plan/survey is not
on site during construction or if the permit has expired.
Permits may be renewed, transferred, or revised in accordance with the procedures described in the
Instructions'to Update an Existing Permit for Single Family Residences (Form WWM-104).
It is the applicant's responsibility to ensure that the Department is contacted in advance to arrange for
inspections of all components of the sewage disposal and/or water supply facilities prior to backfilling or
using. In certain cases, inspections of the soil excavation may be required to determine the acceptability of
the soils for sewage'disposal systems. The Department must be notified by 4:00 pm one business day
prior to the date of the requested inspection by calling 631-852-5754. Also, excavation/soil inspections
must be confirmed by calling 631-852-5700 between 8:30 am and 9:30 am on the morning of the
requested inspection. Article VII of the Sq olk County Code, "Septic Industry Businesses,"requires that
all installers of sanitary systems within Suffolk County shall possess a valid Liquid Waste license from the
Suffolk County Office of Consumer Affairs (631) 853-4600. This office will not perform inspections for
contractors that do not possess a valid Liquid Waste license. It is, therefore, in your best interest to utilize a
sanitary system contractor with the proper license to avoid substantial delays in your project.
Final approval issued by the Department is necessary prior to the occupancy of new buildings,
additions to existing buildings,or for the use of sewage disposal or water supply systems.
SEE REVERSE FOR CONDITIONS FOR OBTAINING FINAL APPROVAL
WWM-058 (Rev. 08/17) Page 1 of 2
Lk/0 C____
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HD Ref. #: SCTM #: z"5- _ Z / (�
CONDITIONS FOR OBTAINING FINAL APPROVAL OF CONSTRUCTED PROJECT:
As a condition of this permit to construct,the following items must be completed as a minimum,prior to
building occupancy or use of the sewage disposal system or water supply facilities. For further information,
refer to`Instructions for Obtaining Final Health Department Approval Of Constructed Projects For Single
Family Residences (Form WWM-041).
INS "E TIONS REQUIRED-For all inspections call 631-852-5754 to request an inspection by I:00 pm,
one�osin ss dtiyprior to the requested inspection day.
'Ekca^ atiott Inspection(s)by the Office of Wastewater Management prior to installation of any leaching
structures to determine acceptability of soils. After requesting, conftrtn the inspection by calling 631-852-
5 700
31-852-5700 between 8:30 ant and 9:30 ain on the morning of the requested inspection. Excavation Inspections are not
p rfornied on Fridays,
015"atiafactory inspection by Office of Wastewater Management of the sewage disposal system/sewage
treatment system.
a,,°S"fatisfactory inspection by Office of Wastewater Management of the water supply for the accessory
ilding(s)
stisfactory
inspection by Office of Wastewater Management of the water supply system.
Satisfactory inspection by Office of Wastewater Management of the sanitary system retaining wall.
El"Check with local Building Dept. to verify if a building permit is required for the installation of an I/A
OWTS (e.g.`electric permit).
DOCUMENTSRE UIREMryKKS
[°Four(4)prints of an As-Built plan (See instructions Form WWM-041)
❑ "Tap letter or equivalent from water district indicating approval of the public water supply
'"Certification from the licensed sewage disposal system installer(Form WWM-078)
"S-9 form" from Suffolk County Department of Public Works, including field sketch(SCDPW)
❑ Sewer district approval of sewer line installation(for other than SCDPW districts)
El"Well drillers report -"dater analysis bya'NY8,certified laboratory (performed within one year)
'Certification of Sewage Disposal System Abandonment(Form WWM-080)
E]"',Signed copy of the Operations&Maintenance Contract for the I/A OWTS
E" Completed Application to Register an I/A OWTS (Form WWM-304)
Ell'—D,esign Professionals Certification of Constructed Works (Form'`WWM-073)for:
❑ Sewer lines and sewage collection system(for public sewer system)
❑ Retaining wall(s) installed as part of the sewage disposal system _ ._..
Sewage pump station/valve chamber(other than VA OWTS) UNOFFICIAL COPY
for price quote purposes only
Sub=surface sewage disposal system(other than I/A OWTS) Reclaim Our Water
OTA OWTS and all related components
Water supply system
❑ Abandonment of Pre-existing sewage disposal system and/or water supply components
❑ Leaching structure(s)/system and all related components
❑ Other:
❑ Other:
Copies of all forms are available from the Department or at wNy",;suf"10 kc tent day I y under"Documents and Forms"
WWM-058 (Rev. 08/17) Page 2 of 2 18-0380P 10/17KK
UNOFFICIAL COPY SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
for price quote purposes only OFFICE OF WASTEWATER MANAGEMENT
Reclaim Our Water 360 YAPHANK AVENUE,SUITE 2C
YAPHANK,NY 11980`
(631)852-5700 OR HealthWWMCRsuffolkcountyny.gov
INSTRUCTIONS FOR OBTAINING FINAL HEALTH DEPARTMENT APPROVAL OF CONSTRUCTED PROJECTS
FOR SINGLE FAMILY RESIDENCES
It is the applicant's responsibility to ensure that the Department is contacted to perform the necessary
inspections of the sewage disposal and/or water supply facilities prior to backfilling. These include inspections
of sewage collection/disposal systems and water supply system components and piping,and final grading as
shown on the approved plans. In certain cases inspections of the soil excavations for sewage disposal systems
as well as other inspections,may be required. To schedule an inspection of the sewage disposal system and/or
water supply facilities,call (631) 852-5754 before 4:00 pm one business day prior to the desired inspection date.
In addition,excavation inspections must be confirmed by calling(631)852-5700 between 830am and 9:30am
on the day of the inspection.
Please be advised that after reviewing the requested information below,the Department may require additional site
inspections including but not limited to exposing additional portions of the sanitary system,water supply,etc.for
reinspection. Following satisfactory construction and inspection of the sewage disposal / sewage collection and
water supply facilities,the following items are required for final approval:
1. Please submit 4 original prints of an "as'-built plan/survey of the property containing a NYS licensed Design
Professional's original stamp and/or signature. Photocopies are not permitted. The as-built plan must
represent the "Post-Construction" condition of the subject property. Structures shall not be labeled as
"proposed"or"Under Construction". The"as'-built"site plan/survey must contain the following information:
a. Lot location,distance to nearest cross street,lot dimensions/metes &bounds,Suffolk County Tax Map
Number and if applicable,subdivision name,subdivision reference number,and lot number.
b. Any and all existin structures on the property including but not limited to: dwelling/building structure,
driveway,sidewalk,swimming pool,fish pond,patio/deck/porch,drywells,storm drains,catch basins
&all drainage structures,geothermal well,irrigation well,fuel tank,underground utilities,etc."
c. If served by an on-site sanitary system,all sewage disposal components on the property(septic tank(s),
leaching pool(s),leaching structures,sewer piping,manhole,etc,)must be clearly depicted. If an
Innovative and Alternative Wastewater Treatment System has been installed,the as-built plan must
also indicate the installed locations of the control panel,electrical wiring,and remote vent piping for
the system. All structures must be drawn to scale,and must be shown in their exact location with
proper structure orientation. Measurements (in feet) must be shown from at least two corners of the
building to the center of the access openings (manholes) of all sewage system components.
Measurements to the septic tank/treatment unit must be shown to the center of the"outlet"manhole
opening. Be sure to also include measurements to any manholes,cleanouts,and leaching structure
access ports on site.
d. If served by public sewers,show the exact location of any sewer lines from the building to the street.
Be sure to include the location of any bends and cleanouts provided on site.
e. The exact location of any and all water supply components on site must be clearly shown. If served by
a private well,you must show measurements (in feet) from at least two corners of the building,to the
center of the well casing. Also show the entire water lateral from the well to the building. If served by
public water show all water lines in their entirety from the building to the street.
f. Show any site conditions that may have developed since the preliminary approval of this project that
may impact the location or functioning of the sanitary system or water supply(standing water,grade
change on adjacent neighbor's property, etc.)
g. HAVE A CLEAR AREA AT LEAST 3"x 5" FOR THE DEPARTMENT'S APPROVAL STAMP.
WWM-041 (Rev. 8/17) Page 1 of 2
2. If any new subsurface sewage disposal system components have been installed,the applicant must submit a
certificate(Form WWW-078 or equivalent)from the licensed sewage disposal installer,attesting that the
system has been constructed according to the criteria of the Department. If a certificate from the installer
cannot be obtained,form WWM-073 completed by a licensed architect or engineer may be submitted.
3. If a well has been installed as the potable water supply,then the applicant must submit a well water analysis
completed within one(1) year by a certified laboratory,and a well driller's report completed by a licensed
well driller. If the well or water quality does not conform to standards,corrective measures will be required
as described in the Department's "Private Water Systems Standards". Please note: water treatment units
may not be installed without prior approval of the Department.
4. If any,pre-existing subsurface sewage disposal system components have been abandoned or removed,the
applicant must submit a Certificate of Abandonment (Form WWM-080) from a licensed contractor,attesting
that the previous system has been abandoned according to the criteria of the Department. If a certificate from
the contractor cannot be obtained,form WWM-073 completed by a licensed architect or engineer maybe
submitted. Any well abandonment must have been performed in accordance with the NYS Department of
Health requirements.
5. If public sewers are utilized,in districts operated by other than Suffolk County the applicant must submit one
(1) copy of the sewer line inspection approval from the sewer district. In districts operated by Suffolk
County,the applicant must contact the Suffolk County Department of Public Works to ensure that all
inspections and S-9 Form requirements are approved.
6. If public water is utilized,and a new water main tap has been installed,a tap letter or equivalent from the
appropriate water district indicating that the water service installation has been completed to the dwelling. If
any seasonal water lines for a cabana,etc.have been installed,provide a written statement from both the
plumber and the homeowner. The plumber must state that the seasonal water line has been provided with the
proper valves and blow-off to facilitate winterization. The homeowner must state that it is acknowledged
that the seasonal water line must be winterized to preventfreezing.
7. In certain cases,the applicant will be required to submit a certification from a licensed design professional,
attesting that all components of the sewage disposal system,retaining wall,sewage pump station,etc. have
been properly:inspected and constructed according to the approved plans and permit conditions. Refer to
"Certification of Constructed Works" (Form WWM-073). Other documents may be required as indicated
on the permit to construct,and on the Permit Conditions (Form WWM-058) attached to your original permit
to construct. Additional information may also be required after review of the documents requested on this
form.
8. If an Innovative and Alternative Onsite Wastewater Treatment System(I/A OWTS)has been installed,
submit a copy of the signed Operations and Maintenance agreement with the licensed O&M provider,as well
as a completed Application to Register an UA OWTS (Form WWM-304).
For a list of specific items required for Final Approval of a certain project,applicants should refer to the Permit
Conditions(Form WWM-058)issued with their stamped approved plans at the time of Approval to Construct.
Copies of all forms are available from the Department or at www.suffolkcountyny.gov
THE HEALTH DEPARTMENT PERMIT REFERENCE NUMBER AND TAX MAP NUMBER
MUST BE ON ALL CORRESPONDENCE OR DOCUMENTS SUBMITTED.
PHOTOCOPIES OF DOCUMENTS WILL NOT BE ACCEPTED AND ALL SIGNATURES MUST BE ORIGINAL
WWM-041 (Rev. 8/17) UNOFFICIAL COPY Page 2 of 2
for price quote purposes only
18.1197..10/17
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