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Home My WebLink AboutSidor ELIZABETH A.NEVILLE,MMC " � � �� Town Hall, 53095 Main Road TOWN CLERK " P.O. Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS411 krlFax(631)765-6145 MARRIAGE OFFICER N)11 Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER j0 www.southoldtownny.gov OF INFORMATION OFFICER r "�' Ygov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TO: Southold Town Building Department FROM: Southold Town Clerk's Office DATED: April 28, 2021 RE: Cesspool Construction/Alteration Application Transmitted herewith is a copy of application No. 4982 for a Cesspool/Septic Tank Construction Permit submitted by: Robert I. Brown Architect P.C. & Agents Ran Sidor 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 Comments: Signature Dated ELIZABETH A. NEVILLE '. Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER Fax (631} 765-fi145 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 @ $10or Non-Residential @ $25 Application No. Permit No. Applicant NamI X.... :.:1 ... � ry ._... ....... Applicant Mailing Address Septic Tank '4 or Cesspool x Brief Description of Proposed Construction or Alteration--A, w w�L AA Location of Proposed Construction/Alteration: Owner of Properly: EbwAM 51W.__ Owner Mailing Address: 5l .._IP" Ave Ah 301 ._. !Y ►000� ._....... Owner Property Address:. 5 Name and phone number of contact person _—A L,,1-16t._.. Jiml. 97�' Tax Map No:"' S ection A ._...._,6` .e_._ ._ Block _..... 1._.............. Lot....._.............ZZ..................e Cross Street, ,MAIN KoA _ . .... ... ...� _ - _. ....... .................. NOTE: LOCATION MAP MUSTBE SUBMI� TED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH I TH DEPARTMENT APPROVAL 2'1 APPA. 101% Si atuz•e of Applicant � ..��.__ ...m .. ..�Date Received b Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 04/28/21 Receipt#: 280067 Quantity Transactions Reference Subtotal 1 Septic Permit- Construct- Resid. 4982 $10.00µ Total Paid: $10.00 Notes: Sidor, Edward (64.-1-22) Payment Type Amount Paid By CK#2102 $10.00 Robert, I Brown Architect Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Robert, I Brown Architect 205 Bay Avenue Greenport, NY 11944 Clerk ID: JENNIFER Internal ID:4982 COUNTY OF SUFFOLK STEVEN BELLONE SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF HEALTH SERVICES GREGSON H. PIGOTT, MD, MPH Commissioner PERMIT CONDITIONS Project Name: 750 Maple Lane Health Services Reference #: R-21-0287 SCTM #: 1000064000100022000 Revision #: 0 The attached plan, when duly signed by a representative of the department, in conjunction with these conditions, constitutes a permit to construct a water supply, sewage disposal, and/or collection system 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 conform with approved plans as well as all 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 having the construction done in conformance with applicable standards. Issuance of this permit shall in no way relieve the 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 the submission of a revised plan and additional fees (if applicable) for approval 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 Instructions to Renew, Extend, or Transfer an Existing Permit for Single Family Residences (Form WWM-104). It is the applicant's responsibility to schedule an inspection of the sewage disposal and/or water supply facilities prior to backfilling. This includes inspections of the sewage collection and disposal systems, water supply system components and piping, and final grading as shown on the approved plans. This can be done by calling the department at(631) 852- 5754, or through the ACA Portal at bLtps:,//aca-pR'od.accela.com/SUFFOLKCO. In certain cases, inspections of the soil excavation may be required to determine the acceptability of the soils for sewage disposal systems. Excavation inspections must be confirmed by calling (631) 852-5700 between 8:30a.m. and 9:30 a.m., the morning of the inspection. Article VII of the Code, "Septic Industry Businesses," requires that all installers of septic systems within shall possess a valid license from the Office of Consumer Affairs. This office will not perform inspections for or grant final approval for construction of projects that are installed by an unlicensed individual. It is, therefore, in your best interest to utilize a cesspool contractor with a valid 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. WWM-016 Page 1 of 2 Project Name: 750 Maple Lane Health Services Reference#: R-21-0287 SCTM #: 1000064000100022000 Revision #: 0 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 and use of the sewage disposal system or water supply facilities. For further information concerning this, refer to Instructions For Obtaining Final Health Department Approval Of Constructed Projects For Single Family Residences (Form WWM-041). INSPECTIONS REQUIRED — For all inspections call 631-852-5754 to request an inspection by 4:00 pm, one business day prior to the requested inspection day. Satisfactory inspection by Office of Wastewater Management of the sewage disposal system /sewage treatment system. DOCUMENTS REQUIRED: Four (4) prints of an As-Built plan (See instructions Form WWM-041 Certification from the licensed sewage disposal system installer (Form WWM-078) Certification of Sewage Disposal System Abandonment (Form WWM-080) WWM-016 Page 2 of 2 AN , LU �) V ^ - r v k1 n xs r� c� ..m...l ....... ",."-".r •,,,r W Z ® uo, Qa• "`»,..,.mlyA N m z ,lulJC .� � QO _ LlizIlI-I a 0 ( F- _ , = C W o / W U ro elf LL W O ". U) I+i p M 4--J V qy h N II �-1 a) ✓ C y (� OF 6. 5z ix ��H//�� O Q n2 r r. " 16 orl �� A� .- �"7 Q VJ [� O CJ] � � NO.G U) :J J S 2 W C w C O of LL Z ti ILL o6- VJ 0 Q w V e G.b + n ^. mi uu g3 9' 'o ul 3.2 7d3J 1, l mow'° crv:' Bry r IJI'D Y Ili dY I1 w•.�7 'L 5(oN 1;704U. 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