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Home My WebLink About3499-zFORM NO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. E:ERTIFIP. ATE OF I-IP.P. UPANP. Y No. Z. 293br ..... Date .......... llovember. 13 .... , 19.67- THIS CERTIFIES that the building located at H!~l. Roa~ ................. Street Map No.(Iiill0.,D./l~l}ck No ............. Lot No....:K~.......t~...th.o.!.ds. ?!'..Y: ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... Jllr~... 1 .... , 19. [~7 pursuant to which Building Permit No. 3~r.c)9. Z. dated .......... ,lime...2 ..... ,19.67, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is P/'.iva.te. one .fa~!ls'. d.ueili~ ....................................... The certificate is issued to . Oltffo~.d. 8abm.....(bmel~. ............................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .Sep.t..~. 1967...bY. R~ .Villa... Building Inspector FOR.~ NO~ 2 TOWS OF soUTsoLD BUILDING D~P^RVM~T TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREM)SES UNTIL FUL.L COMPLETION OF THE WORK AUTHORIZED) N? 3499 z Permission is hereby granted to: ~..~,~,~..~,,:.~,..~.~;~,.~.".:~,. ...... .................. ;~~...~~: ........ : ..... ................................. ~ ........ ~ .......................... ,... -~ .......... . ..? ................... ~...,,, .......... .............................. ~,..~X~ ............................. .......... ..........L.~ ........ ~....~ ............ ~....~.~.....,... pursh~t to opplicofion d~ed ...:.....~.: .............~....~,,.....~ ........~i'¢ .~, ~nd ~prog~ by tho H.D.Ref. No. ~)O -c$~ ~ SUFFOLK COUNTY'DEPARTMENT OF HEALTH EASTERN DISTRICT Couuty 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 ~/{'~(J ~m~ · Address TS' Cw~ec ~,;[ ~T~/~'~ Phone _ 2-Name of Builder ~ 7-Sewage Sy~te~ installed by R~ ~c~e,~ ~/~ 8-(a)Deed location of prop~ty (b)H~let or Village ~OP%A~/~ (c)Town 9-Septic tank-Gal__L__ft.W ft.Liquid Dept~ ft. 10-Cesspools-(a)No.pools ~ (b)Blocks below inlet-l) 2)__3) (c)Block size-L im.W__in.H in.(d)Precast pool ~(e)l~2~ (f)H 7 ft. ~ in; Diem ~fqO in.(g)Finished grade to cover $' ft. (h)Sa~f'ill~aterial ll-Water Supply: Public Syst~ ~ ; Private Well If Private, the following questions are ~o be answered: 12-Private Water Supply Syst~ installed by Phone Address 3-Subdiv. C lv s/ k 4-Section.No. ..5-Lot Number 6-Bldg.Permit No. ~Z/~g~ ~hone /;'~ ~ ~ 13(a)-Total Depth of Well 14-Diameter of well pip~ 15-Name of Laboratory 17-Date ready for inspection (b)Depth to Static Water Level in. 16-Method of Disinfection 7 · The undersigned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's currents, Bulletins and Amendments thereto. ~/: / 19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. STREET O LY Based n ~he ~nfo~a~on s~a~ed above, sa~isf~ctory ~unc~2on~g of ~he above systems can be expected w~h proper maintenance and c~re, S-5e ~structions ~or Submission of Installed Private Sewage Disposal and Water System Application Applications are to be submitted in duplicate. Required information should be typed or legibly printed in ink. Inspectors are not permitted to make inspections of installations until applications have been submitted to and accepted by this de~ partment. The item number on the application form ahd, item,number listed below are the l, Otmer's, name and address - if o~ner and builder are same, so indicate. 2, Builder's name and address - approvals willbe mailed co 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) For example: s/s Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated area in to~mship), for example: East Horiches. Village (incorporated area), for example: Northport. (c) Totmship, for example: Brookhaven, etc. 9. Give inside length and width in feet. Liquid depth is measured in feeC from bottom of outlet pipe to bottom of tank. lO. (a) State number of pools. (b) State number of blocks below inlet pipe for each pool. (c) State length, width, and height of cesspool blocks 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. ll. Indicate by check if water supply is public or private. i[2. 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 well point. (b) Depth in feet from top of well pipe or casing to water level in well. 14. Inside diameter of well casing. 15. Nume 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 allowed to stand six hours. 17. State date on which installation will be ready for inspection. 18, Application must be signed by builder or o~ner. Signatures of subcontractor, superintendent, etc., will not be accepted. ~9. Indicate location of Water & Sewerage Facilities with accurate dimensions on sketch, FOI~I~I NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ....~:.....~... ....... Approved ........................................ , 1c) ........ Permit No ................................. Disapp rove~ .............. .... ................... ..................................... (Building Inspeftor) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS o. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of propertymust be drawn on the diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the progress of the work. e. No building shall be occupied or used in whole or in part For any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code and regula~t;ions. (Sig a ure of,~pplicant, or name, if a corporation) ............... ......... ~/ (Address of applicant) ~,/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ....................... .~=-.~/~.-.- .............. ': .............................................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Location of land on which proposed work will be done. Map No: ................ ~...~.. ................. ,....~L~t No: .................... Street and Number ............. t ........................................................................................ Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: 3. Nature of work (check which applicable): New Building c~" Addition A~terotion Repair .................... Removal .................... Demolition .................... Other Work (Describe) ...................................... ~6~, d)00 Fee 4. Estimated Cost ......................... ~ ........................................................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ................~.. ......... Number of dwelling units on each floor ........... .2.. .............. If garage, number of cars '~ ............ · · 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ................................ 7. Dimensions of existing structures, if any: Front .......................... Rear .......................... Depth ............................ Height ............................ Number of Stories ............................................................................................................... Dimensions of same structure with alterations or additions'. Front ................................ Rear ................................ Depth .............................. Height .............................. Number of Stories ........................................ 8. Dimensions of entire new construction: Front ............. ~.~ ........Rear ............ .~..?~. .......... Depth ......~,:'..~....'./...c{.fl ...... Height .......... ~.~.~:. .......... Number of Stories ........ /. .................. 9. Size of lot: Front ....... ./.~.r.>. .............. Rear ....... ,/.~.~. ............. Depth ........ .~.~?. ............... 10. Date of Purchase ........................................................ Name of Former Owner ........ ~,......~...9~.\..r.?..~.......~. L./.../. ......... 11. Zone or use district in which premises are situated ................................................................................................. 12. Does proposed construction violate any zoning law, ordinance or regulation~ /1~ . .- ....... ' ..................... 13. Name of Owner of premises ....... ~ .......... ./) ................. Address ..~..~....: ................................. Phone No ..................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor ....~..e...~:.~..d.....:X..CL..C..~:.~ ................. Address ..... ~:.v.~.}.~:.t.~.?.~...:.~..::. ........ Phone No ..................... 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 numbers or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF ................................ / S.S. , , .......................................... being duly sworn, dep,qses and says that he is the applicant ............... i~l'~'~"~: 'i~i~'i~'~i" 'sig n i ~ application) (Contrd'~tor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or hove performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to I~efore me this ~ 19 1~ ........ day of . ..L'Z~ .................... , Notary Pu~ ~....~.,..~~Cq~ ~ ~t~,?',). ", ~'~ignature of applicant) " / / ~OTARY