HomeMy WebLinkAboutBarnes ELIZABETH A.NEVILLE,MMC ��' �� '� Town Hall,53095 Main Road
TOWN CLERK P.O. Box 1179
r
� y Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ad i° � � y�� Fax(631)765-6145
MARRIAGE OFFICER °�
r �,� ° �,�����" Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: September 9, 2020
Transmitted herewith is a copy of application No. 4869 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Lucinda Barnes
Please review the application and location map and advise if the project has received Suffolk County
Health Department approval and 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
Comments: Maintain re uired setbacks from„adjacent wells, �ildi;11) ro ert lines and water
Bodies. EXCAVATION IN:SPECT1,01 1ZI l RED.
Signature
Dated
�.A
"k1k,
own Hall, 53095 Main Road
ELIZABETH A.NEVILLE
P.O. Box 1179
TOWN CLERK
Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS w ""
GE FFICER Fax(631) 765-6145
a
ECO AGE FIC ;�µ ��� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APP1..ICATION
CONSTRUCTION P ALTERATION PERMIT
CESSPOOL P SEPTIC TANK
Residential 10 or Non-Residential @$25 ApplicationNo. '
Permit No.
Applicant Mailing Ad(h-ess,... ��� ....� , .. �! �d�.. .. . _.
Septic Tank or Cesspool
'efDescri tion of Proposed Construction or All C w"Itio�i�
v � ,
Location of Proposed Construction/Alteration:
i , 4'&
Owner of roe
Owner Mailing Address ... ...� .��.��_ . '" �.� ....... ...................... ..........--
Owner property Address: .. d ..
Name and phone number of contact person ._ .. .� .... _,_ �
Tax Map No: Section Lot __--_ l
Cross Street
NOTE® LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH A T T ,NT'APP.RO A:I:.'
� ,..
Signature of,, l.icklp- � t t��
Received by
COUNTY OF SUFFOLK
o
1-4
�JM�,�
SEN,BI:rLLONf_ 0 4x��"%"
SUFFOLK COUthY XE'dtAVE' �
DEPARTMENT OF HEALTH SERVICES JAMES L.°TOMARKEN, MQ, MPH, MBA,MSW
Commissioner
E, ,TT ONO
A111 An,"
Health Services Reference#
The attached plan, when duly signed by a representative of the,Qepartment, 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°weld as applicable
standards including "Standards for Approval of Plans and Construction for Sewage Disposal.Systems
for Single Family Residences.- Omissions,,ineonsistencies 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,acceptabilityof
the soils for sewage disposal systems. The Department must be notified by°4:04 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-$52-5700 between 8:34 am and 9:30 am on the morning,of the
requested inspection, Article VII of the Suffolk County Code, "Septic Industry Businesses," requires that
all installers of sanitary systems within Suffolk County shallpossess 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 I oft
112
HD Ref. #. ° t� " "; .,.� if SCTM#: y N A
CONDITIONS FOR OBTAINING FINAL APPROVAL OF CONLSUUCTED 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 disposa1'system or water supply facilities, F nfi rther information,
'
�/�n �al� Y��Iar140ipi/a
refer to Instructions for Obtaining Final Healthepgrtme,,n-t ApprougG,Of Con, tdrycted Projects For Single
Family Residences (Form WWM-0=11).
'D- For all inspections call 631452-5754 to request an inspection by 4:00 pm,
one business day prior to the requested inspection day.
Excavation Inspection(s) by the Office of Wastewater Managerrief/t�priou omstallation of any leaching
structures to determine acceptability of soils.'After requesting, confirm theins�ection by calling 631-852-
" 'F5700 between 8:30 am and 9:30 am on the morning of the requested inspection. Excavation Inspections are not
Terformed on Fridays.
Satisfactory inspection by Office of Wastewater Managemeftof;t�e,sewage disposal system/sewage
r �yfr,v
treatment system.
Satisfactory inspection by Office of Wastewater Management the water supply for the accessory
building(s).
❑,, Satisfactory inspection by Office of Wastewater Management of the water supply system.
❑ Satisfactory inspection by Office of Wastewater Management of the sanitary system retaining wall.
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).
Four(4)prints of an As-Built plan (See instructions Form WWM-041)
EJ "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)
❑ Well drillers report ❑ Water analysis by a NYS certified laboratory (performed within one year)
Certification of Sewage Disposal System Abandonment(Form WWM-080)
El Signed copy of the Operations &Maintenance Contract for the I/A OWTS
Completed Application to Register an I/A OWTS (Form WWM-304)
Design Professionals Certification,of Constructed Works (Form WWM-073)for:
❑ Sewer, lines and sewage collection system (for public sewer system)
Retaining wall(s) installed as partof the sewage disposal system
Sewage pump station/valve chamber(other than I/A OWTS)
Sub-surface sewage disposal system (other than ]/A OWTS)
I/A OWTS and all related components
El Water supply system
Abandonment of Pre-existing sewage disposal system and/or water supply componlents
Leaching structure(s)/system and all related components
Other:
❑ Other:
Copies of all forms are available from the Department or at t,, Wu ,g ,�(b,p ]runder"Documents and Forms"
WWM-058 (Rev. 08/17) Page 2 of 2 18-0380P 10/17KK
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/09/20 Receipt#: 274698
Quantity Transactions Reference Subtotal
1 Septic Permit- Construct- Resid 4869 $10.00
Total Paid: $10.00
Notes:
Payment Type Amount Paid By
CASH $10.00 Barnes, Lucinda
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Barnes, Lucinda
209 West 97th Street
New York, NY 10025
Clerk ID: SABRINA Internal ID:4869
/
MAP OF PROPERTY
, � / / L• A T GREENPORT
C
2"FORCED MAIN DETAIL TOWN OF SOUTHOLD,
N.T.S. CO. OF SUFFOLK, ST. OF N.Y./Avl / •�� ' / SCTMNO. 1000 - 40 - 01 - 21
a / �,,69.1ti
?==30'
SCALE w
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REVISION: 18 JUN 2018 ADD PROP.POOL,DUCK,
POOL HOUSE&SS SYSTEM. / r,/s LIPA19
REV1SlON:28 JUN 2019 REVISE PROP.POOL_,DECK, �/ �
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REVISION: 15 JULY 2019 REVISE PROP.POOL, DECK, `, •� /\ // // ey9ti' :',f� 0 rt p►
UNDERGROUND UTILITIES PER POOL HOUSE_ &SS SYSTEM.
JOHN C.EHLERS SURVEY 09 JULY 2013 REVISION:05 NOV 2.019 ADD UTILITIES UT EASEMAENT � (//! � 1`l�� // .;.,;w;.��;•: `�q
REVISION:01 FF.R?.020 FORCE.MAIN PROFILE \ /A i,`� •;.;ry�':�:•.�:,"' �.
OWNER(.�''). MS. LUCY BARNES ST POSITION EJECTOR PUMP PER A.L. 14 AUG /• / / '�"�:'�L Q
_..__ .. _...._. COMMENTS ` // Q,r.'"'} 4 *' �►
REVISION:30 APRiL 2020 F.M.PROFILE(4.5 COVER)
THE OFPSL13 ORn/MFNSIONS SHOWN HFHONFROM THF PROPERTYLiNCS 710
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OFFF.NCF_.S,ADD/TIONALSIRUCIURFSORANY OTIfGRIMPROVrML:Nr. •' `«"
REVISION: 15 JUN 2020 ZOELLER X840 DUPLEX
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SECTION 7209SUADiVISON 20 orTI1ENEW YORK STATFEDUCATION LAW. COPtFS •� ` •� "�" "�•'�'
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THF SIORVFYIS PREPARED, AND ON THEIR aENALrTO77N:MIF.COMPANY,,GOV LAND SURVEYOR NY LIC.
ERNMFlJT AGENCY AND LFNniN(4 INSTITUTION USTlU HERE ON. CfRTIF1CATIONS DATUM r9 A"hRENCED TO MSL NOVD n AS SHOWN ON SURVEYBY 50869
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