HomeMy WebLinkAboutSilverstein ELIZABETH A.NEVILLE,MMC Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �;�� „i��j '� Fax(631)765-6145
MARRIAGE OFFICER � ' „� 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: May 24, 2021
Transmitted herewith is a copy of application No. 5015 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
A-1 Community Cesspool Services for Scott Silverstein
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 rcruir acks lz�t� n Ojmacent wells,jLi,,ildings, property lines and water
Bodies. EXCAVATION INSPECTION RE UIRED.
Signature
...................
Dated
ELIZABETH A. NEVILLE ��am own Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Ze 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 � �, �' Bout of town.north ork. et
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION r ALTERATION PERMIT
CESSPOOL 1'SEPTIC TANK
X '
Residential $l or Non- esi ential 5 Application No.
Permit No.
Applicant a e .._L :. . .. n
-----
Applicant Mallin )cress_ A' .
_ _......................_........._........... _.............
SepticTank1j. or Cesspool
r�j ' a.
1ptio1 Construction or ntim
m ........ - � �
Locat,iob Of P op ossa f,ojistrUctioji/; erallori:
Owner of Nop rty:......,mm :.. wcr
g .t`. /� � � .;
Owner Mallin Address:
Owner Property Address:..°..... ... ...........®....
Name and phone number of contact person -, ro I. m
'fax Map No: Section. _......,.... Bloch � .�........_ Lot 00' (� z✓000
Cross „Street
O'm, LOCXTION MAP MUST ]IBE Sul-)m'rr "le.lWITH Al"I'L.111CATION. NEW
CONSTIR.UCTION REQ111RES SURVEY rl ° 1 lll� �"1'� � ��� 1 .°i" 11c,NT A PP1ZOVAL
i � �tl t �'a;fApplicant
. �ule
9.
Received.by:
Suffolk County Department of Health Services
Office of Wastewater Management
360 Yaphank Avenue,Suite 2C
Yaphank,New York 11980
(631)852-5700 OR HealthWWM@suffolkcountyny.gov
CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER
Leave blank any items that are not applicable to the installation. **A sera&,.vfloral s, stem sketch along-ovith
location measurements Lynn at least two building,cornerstnivy he providedon the back,gr on a separate sheet
and attached to this farm**
Health Department Reference Number: SHIP ENTRY#21-00044 .....
Suffolk Tax Map#:Dist: wmmm Sect(s) Lot(s) 1000079000100004000
Project Name or Address: mmIT500 GOOSE CREEK LANE SOUTHOLD NY 11971
Applicant/Homeowner Name: SCOTT SILVERSTEIN
Date of System Installation: 1 /22/21
IIA OWTS TREATMENT UNIT SEPTIC TANK
Make and Model: Volume (gallons): 1250 GALLONS
Rated Daily Treatment Capacity (gallons): Material: Concrete, [] Fiberglass/Plastic
Material: [] Concrete [ ] Fiberglass/Plastic Shape: Rectangular, N Cylindrical
DISTRIBUTION LEACHING POOLS(If applicable) Top: Slab, [3 Traffic Slab, [] Dome
Number of Pools Name of Tank Manufacturer:AFFORDABLE
Diameter and Effective Depth GREASE TRAP
Top: [ ] Slab [ ] Traffic Slab Dome Volume(gallons):
Name of Precast Manufacturer: Material: Concrete, Fiberglass/Plastic
................ Top: Slab, [] Traffic Slab, Dome
LEACHING POOLS/GALLEYS Name of Tank Manufacturer:
Total Number of Pools/Galleys 5 OTHER LEACHING STRUCTURES
Diameter/Dimensions and Effective Depth 3X8 Make and Model (if applicable):
Top: Slab [)J Traffic Slab Dome
N/A
Name of Precast Manufacturer: AFFORDABLE Total Linear Feet of Leaching Structure(s):
COVE AND LIDS
Installed covers comply with current standards (secondary safety device installed if cover weight less than
60lbs.) [] Yes [ ]N/A
I hereby certify that the subsurface sewage disposal system components described herein,have been installed by me in accordance with the
approved plans and/or standards of the Suffolk County Department offlealth Services as well as any other municipal agency requirements;and
any and all mechanical/electrical components have been tested and are operational in accordance with manufacturer's recommendations.
Installer's Signature: Date 1/22/21
John M
Installer's Name:7�ktotta
Company Name: Al COMMUNITY CESSPOOL SERV_CES ..............—Phone 631-234-3070
Company Address:-180 BLYDENBURGH ROAD ISLANDIA NY 11749
Consumer Affairs Liquid Waste License Number and endorsement(s): LW-55110
"INADDITION TO ABOVE, COMPLETE BELOW FOR SANITARYREPLACEMENT IRETROFIT ONL Y.
In addition to the above information,I hereby certify that this OWTS replacement or retrofit meets the Department Replacement/Retrofit
Standards, and that other alternatives are not environmentally feasible. I also certify that this OWTS replacement or retrofit installation
repre;ents an improvement to existing sewage disposal system conditions.
I
Installer's Signature, . .......................
Installer's Name: JOHN MOTTA
THIS DOCUMENT MUST CONTAIN ORIGINAL SIGNATURES FROM THE INSTALLER
WWM-078 (06/19)
B
A
N
O
A B
SEPTIC TANK
STI 1 25' :]�39'
LEACHING POOL(S)
DPI 42' 53'
O O
O
1
O
O