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ELIZABETH A. NEVILLE � �• Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF 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 @ $10 or Non-Residential @ $25 Application No.
Permit No.
4 � . ..Applicant Name_
Applicant Mailing Address ��� � _�......
Septic Tank or Cesspool _-mmITITIT
Brief Description of Proposed Construction or Alteration,
Location of Proposed Construction/Alteration:
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Owner of Property: ._._... _.m
mm � '
Owner Mailing Address:, �m _ ",�' ,m,_,m, m
Owner Property Address: ka,(A,
Name and phone number of contact person._
W. ..
Tax Map No:Co 00 Section Block - Lot m �°
Cross Street
NOTE: LOCATION MAP MUST ,$U MI"I TED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES S ?lVXWI" H HEALTH DEPARTMENT APPROVAL
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Signature ofAfi icant Date
Received by: ""°
SANITARY NOTES:
D. E 1, SURVEY BY NATHAN TAFT CORWIN III LAND SURVEYOR DATED
TgS 9 JANUARY 7,2010.
N 2, EXISTING TOPOGRAPHY REFERENCES THE NAVD'88 DATUM
FROM SUFFOLK COUNTY GIS VIEWER.
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p 3. THERE ARE NO WELLS WITHIN 150'OF THE PROPOSED
o SEWAGE DISPOSAL SYSTEM.
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Z 4. THERE ARE NO WETLANDS WITHIN 300'OF THE PROPERTY.
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C
o _ Co " DSP F i IL = SERA
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thl
cm Based on the in-fortw-tion siibm'_tce-l-it bas be 'erM OV I
-70 ect does not rcquff
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Dam
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8'0 X B'DEEP 50%
EXP
LEACHING POOL
� A:44.5' °*
tz B:48.0'
t A:34.5'
B.49.0. 00
3-
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2-8'0 X 8'DEEP
LEACHING POOLS ►
2000 GALLON
j 3 SEPTIC TANK 6:28.0' C '
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AREA: LOT AREA:25,062 S.F.
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WEmsSCDHS REF. NO.: R-20-0049
Plans are prepared byCQndon E PC- It a vidlatfon of e N York VIDAL RESIDENCE
State Education Law,M-99
,for y person ung ading
7""
Scale:1-4Y-0 Condon Engineering, P.C.
urKW the directon of a licensed ProfessidFral Enghw,Architea or Land 7995 MAIN ROAD
MattituckNew
Surveyor,to alter any item in any way.If an item bearing the seal of an Engineer, Drawn by:JJC 1755 ,New a Road Yolk 11952 EAST MARION, NY
Architect,or Land Surveyor is altered,the aftering Engineer,Architect,or Land
Surveyor shall affix to the item his/her seal and the notation"Altered by"followed (631)298-1986(631)298-2651 fax
by his/her signature and the date of such alterations,and a specific description of Date:120 SCD19
1/1712020 SCDHS COMM WWW.COndOnen9lrteering.CX)rl'1 SANITARY AS—BUILT
the afteratan.