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Home My WebLink About4071-zFOI~M NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerli icnte Occupnncy No.. Z~!SJ.. .... Date .............. Apri~ .. 1..., 19.7.1. THIS CERTIFIES that the building located at . I¥S .B&}, .¥~.~. ll~t4[ ...... Street Map No...~ ....... Block No .... ~ ..... Lot No ..... ~ ..... Se~thel& ... N..~. .... confoms substantially to the Application for Building Permit heretofore filed in this office dated .......... Sept...30-, 1968. p~su~t to which Building Permit No...~1. Z dated .......... 0~...~ ..... , 19.~8., was issued, ~d conforms to all of the require- men~ of the applicable provisions of the law. The occup~cy for which this certificate is issued is ... P~tva~. erie .~$.~y. d~ell~[. .................................... The certificate is issued to . .Pa~ .H~-~er ......... ~er ........................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .~eV-...18 .... 1~0 · · by- .R ,. V-illa. · · FORM NO. 2 TOWN OF SOUTNOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) H.° 4071 Z Dote ....................... .JJJl~ ....... .~ ................ , 19...~. Permission is hereby granted to: ~,.~J~lti, t~..~.~,,l~.~...~.oM~.~w...~o.~....;,/C Paul. ~Jtez ................................ IIm~Z~l ......... J.~Z~. ......................................................................................... pursuant' to application dated ............................. ~lil~j .......... ,~ ...... , 19.1~.., and approved by the Building Inspector. Fee $.. ~.~.*~ .......... S-9 SCHD SUFFOLK COUNTY DEPARTHENT OF HEALTH J TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located / / (Give d%ed location) have been inspected by this department and found to be satisfactory. Chief of General Dngineerin~ ~or¥ices District Engineer SUFFOLK COUNTY DEPARTMENT OF HEALTH EASTERN DISTRICT County Center, Riverhead, New York PA 7-4700 APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS Inspection for approval is requested, pertinent installation data herewith. 1-Name of Owner ;',~A Address ~A/# S~, ~,~F Phone ~o~-~ ~ 2-Name of Builder ~xO~/r~ ~ ~ ~ Phone~o~-- ~y 9~ Address ~o~r~ H~ ~,, 7-S~age Sys~ installed ~y ~ M Address ~R~ ~.~/~ ~ ~ 8-(a)Deed location of property ~/~ ~F~/~ ~7/~e~/~ c~ (b)~let ~ ~ (c)T~ 0-Septic ~ank-Gal__L ft.~ ft.Liquid DeptCft. 10-Cesspools- (a)No.pools ~(b) ~loc~ belo~ inlet-1)~2)/fJ (c)Block size-L /~ im.~ ~ in.~ ff in.(d)Precast pool (f)~__ft.__in; Di~ ft. in. (g)Finished grade to cover (h)Backfill ~te~ial ~ ll-Water Supply: Public Syst~ ; Private Well If Private, the foll~ing questions are ~o be answered: 12-Private Water Supply Syst~ installed by Phone Address 3-Subdiv. i-Section No. 5-Lot Number 6-Bldg.Pemit No. ~?; ~ Phone -e~2- ~to F (e)l_ 2 /-.~ ft. 13(a)-Total Depth of Well (b)Depth to Static Water Level 14-Diameter of well pip~ in. 15-Name of Laboratory 16-Method of Disinfection 17-Date ready for inspection~'~-~. ~.,/~'~ . The undersi~ned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's current Standards, Bulletins and thereto. _~ ~ '~er - Builder 19-Insert sketch of location of Wat~t~&o,Severage Facilities with accurate dimensions. liS" . FOR HEALTH DEPARTMENT~USE ONIY ' Based upon cae lnzormation stated above, satisfactory functioning of the above bystems can be expected with proper maintenance and care. S-Se ~nstructions for Submission o£ Installed Private Sewage Disposal end Vater Syste= Application Applications are to be submitted in duplicate. Required infor~ation should be typed or legibly printed in ink. Inspectors are not pez~itted to make inspections of installations until applications have been submitted to and accepted by this de- partment. The item nt~aber on the application form and item number listed below are the ss~e: 1. Owner's name and address - if owner and builder are same, so indicate. 2. Builder's name and address - approvals will be mailed to this address. 3. Give name of filed realty subdivision map. 4. Section number of realty subdivision map. 5. Lot number of plot on which disposal unit is constructed. 6. Building permit number assigned by the Building Department. 7. Name of person or firm who actually constructed the sewage disposal facilities. 8. (a) Rot example: s/s Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated area in township), for example: East ~oriches. Village (incorporated area), for example: Northport. (c) Township, for example: Brookhaven, etc. 9. Give inside length and width in feet. Liquid depth is measured in feet from bottam of outlet pipe to bottom of tank. 10. (a) State number of pools. (b) State number of blocks below inlet pipe for each pool. (c) State length, width, and height of cesspool block~ in inches. (d) Indicate by check if precast sections are used. (e) Give number of leach- ing sections per pool. (f) Give height and diameter of each leaching section. (g) Give depth in feet from finished grade to cesspool cover. (h) Describe backfill material used. 11. Indicate by check if water supply is public or private. 12. Name of person or firm who actually installed the water supply facilities. 13. (a) Give depth in feet from top of well pipe or casing to wei1 point. (b) Depth in feet from top of well pipe or casing to water level in well. 14. lnside diameter of well casing. 15. Name of laboratory performing the examinations. 16. Describe method of disinfection, for example: quart of laundry bleach in ten gallons of water poured into well and allov~ to stand six hours. l?. State date on which installation will be ready for~flspection. 18. Application must be signed by builder or owner. Signatures of subcontractor, superintendent, etc., will not be accepte~. 19. Indicate location of Water & Sewerage Facilit'ies with accurate dimensions on sketch. A~ ........................................ , 19 ........ Pe~t No. ~U...L..'..........~ .... D~pp~ed a/c .................................................................. ... ~ ,/. /__ .~ ~a . ................................................................................ v"'~ ............. I~1 ' ': · . b ............ ~ .............. .~... // ........................... ....... · ' - ~_~/~/~ ~-~ INSTRUCTIONS I " a. ~is applicati~ must ~ ~o~pletely fill~ i~ ~y ~ewriter or in ink a~ su~mi~ in ~plicQte to the Buildi~ Ink,tar. b. Plot plan s~ing I~ation oJ I~t and of buildings ~ premiss, relatim~ip areas, and giving a ~Qile~ ~ripti~ of I~t of p~ must ~ ~rat~ on t~e ~ia~ram ~i~ is ~ of ~i~ ~pll~Qti~. c. ~e *o~k covered ~y t~is ~plica~i~ m~ not ~e ~ommenced before iss~e d. Up~ approval of t~is applicati~, t~ Building Ins~ctor will i~ue Q Building Pe~it shall ~e kept on t~e premiss available for i~tim t~u~hout t~e pr~rKs e. No ~uil~ing s~ll ~ ~cupi~ or u~ in ~ole or in pa~ for any p~ose w~atever u~til s~ll ~ave ~een granted ~y the Buil~i~ In~Ktor. APPLICATION IS HEREBY MADE to the Building D&l~drfm ' of 9 Building Zone Ordinance of the Town of Southold, ~folk County, New York, and otl~ Regulations, for the construction of buildings, oddit~ol~s or alterations, or for removal The applicant agrees to comply with all applicable I~ws, ordinances, building code /- ......... .... I .-~ of applicol / (Addres State whether applicant is owner, lessee, agent, architect, engineer, general contractm Jelectrician, plumber or builder. Name of owner of premises ....... ~...~.~)~1.~, ....... ~'~.~.~LmJT__, ..........................................! .................................................... If applicant is a corporate, signature of a'OT~authori'Jed officer. '" ........ ...................... '"- ~' (Name and title of corporate officer) Building Permit pursuant to the tr applicable Laws, Ordinances or r demolition, as herein described. regulations. ............ ~t, or name, if a corporation) ............................ of applicant) 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No.: ........................ Street and Number .....~'..~.A~.Z~......~/.~R~. ............ ~.~...~.$~:M?"'.....~:~.....~./'~J~'.~4~..~.,~.x...t~:~..~tl~/~' Municipality 2. State existfng use and occupancy of premises and intended use 'and oCcbj~ancy of~ropased construction: a. Existing use and occupancy ................................................................................................................................... b. Intended use and occupancy .......... ~...l~../.~r~.~.~.. ............................................................................................ 3. Nature of work (check which applicable): New Building ;~..~. ....... Addition .................. Alteration .................. Repair .................. Removal .................. Demolition ................... Other Work (Describe) ........................................ 4. Estimated Cost ....~c~:~.~...~.. .................................. Fee ..~'.~.:..~ ............................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ......... /...~ ............. Number of dwelling units on each floor ............................ If garage, number of cars .../ ............... ~i~ ...................................................................................................... ~..;..~ ....... ~. 6. If business, commercial or mixed o~c~pancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, ifony: Front ............................ Rear ................................ Depth .................... Height ...... ~ ................. Number of Stories. ................... i....;~ ..................................................... ; ........................ ~ ...... ~ Dimensions of same structure"with alter~io~ or addition~: Front .................................... Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ / 8. Dimensions of entire new co~truction: Front ......... ~LI~...~. ................... Rear ....~.~ ................ Depth .~ ................ Height ...~*~.~ ........NUmber of St0ries"iiil/...~ ............. ; ........................................................................................... 9. Size of lot: Front ...... .'~-~.~. .............. Rear ....... IfaD. ....................... Depth ......~k~....t~ .......... 10. Date of Purchase ..~t~'~l~.. ................................ Name of Former Owner ..~.,...~ ................... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed constraction violate any zoning law, ordinance or regulation? .....~..~ .................................................. 13. Name of Owner of premises ~.~..,..~l~c..~.~.~x~:..Address ..~,~,&~2~...,~./ ....... Phone No ..................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .~'~.~'~.....~....~.., ............. Address ...~/.~x~l~.~..,~A~.~. ....... Phone No. g .~....*.~..~..~.... · PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, ).cc COUNTY OF ................................ ~' '~"~' (Name of individual signing application) above named. He is the ~,....~~ ................................................................................................................ (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to ~:ke and file this application; that all statements contained in this ap~i~a?on are tr2e to the best of his knowledge and belief; and that the work will be performed in the manner set fo~h in th~ appliCati~: fil~ ther~ith. Sworn to before me this Noto~ Public~~~~ Coun~ (Signoture of applicant)