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Home My WebLink About3563-z~ORM ~0. 4 ?OWN OF SOUTI~OLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, I~. ¥. OERT] FJO~TE OF THIS CERTIFIES that the building located at .~.~..~..~..~y.0.~?.O..~.~..~..~.~.e. ....... Street Sal~al~e Map No ............. Block No .... ~ ....... Lot No. ~, ..... ~a~l~Ok., .~.,.~* ...... conforms substantially ~o the Applicati,on for Building Permit hereto2Gre filed in this office dated .......... ~.., 19.6~ pursuant to which Building Permit No.~6~... dated ......... ~q~ .... ~..., 19~., was issued, and conforms to all of the require- merits .of the .applicable provisions of the law. The .occupancy ~or which this certificate is issued is .~X~ .9~. }[g¢~Y..~¥~l}~g ........................................... The ce~ificate is issued ~o ...[{¢~,P~. ~.~Jl ........... Q~a~ ....................... (owner, lessee or tenant) of the aforesaid building. .Suffolk County Department of Health Approval .Sapg...26.~. ~6~.... by. R,~I].~ .... Building Inspeetor~ FOI~ NO. 2 TOWN OP 50~TNOLD BUILDING DEPARTJV~ENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y, BUILDING pERMIT (THIS PER~IT MUST BE K~EPT ON'THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 3563 Z .... l~.~t ~"t ¢,.~o.~.:....~.~..~.z ........... : .......... ,o ..]3..q.t..~.A...:~.'~..~.'.:.~..L ~..,~.~.. ~.~.V. ........ ~..c~..~...G .................. : ................ ' 'd~ ~emises located at ,~.~....~'. ..... .~:.0. :d ............ .~..~...~.....~.~i:~..../J~..;...~.~. ~.. ....... ........... :Jt.q..~...~.& ~..r...~'..,~ ............... ~I3...,4,.~ ....~.~,.c,~ ................................. Building InsPector.. Fee ~ B~ilding inspector J ' 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 OwnerR~ /'R~/;f~/ 3-Subdiv.-g~f~/ Addrese ~7 RU/~/~z~ ~, ~f~F~,~ Phone ~-section No. 2-Name of Builder ~ ~ Phone~5-Lot Number Address ~ ~XM~ ~, ~/~ ~F~ ~ 6-Bldg. Pe~it No.3~3~ 7-Sewage System installed %y~ ~ Phone ~ Address ~D 3~, ~/~ ~ ~ /1~ ~ (b)H~let or Village ~F~ ' (c)Town 9-Septic tank-Ga~ L__ft,W ft,Llquid Depth 10-Cesspools-(a)No.pools ~ (b)Blocks below inlet-l) ...... 2) 3) (c)Block size-L in.W in.H in.(d)Precast pool ~ (e)~2~3~ (f)H~ft. ~ in; Diam~ft. ~ in.(g)Finished grade to cover ~ ft. (h)Backfill'Mat'erial~. ll-Water Supply: Public Syst~ ; Private Well .~ If Private, the following questions are to be answered: 12-Priva~e Water Supply System installed bX Phone Address 13(a)-Total Depth of Well 14-Diameter of well pipe 15-Name of LaboratorM 17-Date ready for inspection (b)Depth to Static Water Level in. 16-Method of Disinfection The undersigned CERTIFIES: Above systems have b~ constructed and are in compliance with the Suffolk County Health Depart]~'s cg~J~pt Standards, Bulletins and Amendments thereto. //',///~/~--/'~f.--/- '~ ~ ~ ~ Owne~ - Builder ~- 19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. STREET ................................................................ FOR HEALTH DEPARTMENT USE ONLY Inspected by ~ ~.~_~._~. Date //~ ~ ~ ~ ~/~ Based upon the information stated above, satisfactory functioning of the above systems can be expected with proper maintenance and care. /- :-'0, ?/:? D:.s~r~c ~ Engineer: S-Se ~nstruc~tons for Submission of Installed Private Sewage Disposal and W~ter Syste~App,licatio i Applications are Co be submitted in duplicate. Required infor~ation should be o~f~ndsOr legibly orinted in ink, Inspectors are not permitted to make inspections tallations until applications have been submitted to and accepted by this de- partment. ; The item number on the application form a~d item ntmber listed below are the 1. O~er's neme and address - if o~mer and builder are same, so indicate. 2. iBuilder's name and address - approvals will be mailed to this address. 3. Give name of filed realty subdivision map. Section number of realty subdivision map. 5. ]Lot ntmber 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. l(a) For example: s/s Jones St., lOO' e/o Smith St. (b) Hamlet, (unincorporated ~area in to~raship), for example: East Moriches. Village (incorporated area), ifor example: Northport. (c) To~nship, for example: Brookhaven, etc. 9. IGive inside length and width in feet, Liquid depth is measured in feet from /bottom of outlet pipe to bottom of tank. 10. ](a) State number of pools. (b) State number of blocks below inlet pipe for leach pool. (c) State length, width, and height of cesspool blocks in inches. ](d) Indicate by check if pretest sections are used. (e) Give number of leach- iing sections per pool. (f) Give height and diameter of each leaching section. !(g) Give depth in feet from finished grade to clsspool cover. (h) Describe ;backfill material used. I1. ilndicate 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 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. 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 allowed to stand six hours. 17. State'date on which installation will be ready for inspection. 18, Application must be signed by builder or owner. Signatures of subcontractor, superintendent, etc., will pot be accepted. ~9. Indicate location of Water & Sewerage Facilities with accurate dimensions on sketch. S-9 SCHD SUFFOLK COUN'I¥ DEPAR'IMEN'I OF HEAL'iH TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located (GiveZdeed loc~tion) have been inspected by this department and found to be satisfactory. FOl~[ NO. ! TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined .............. .(~ ........................... Approved ................... :.! .................. , 19..'.!.... Permit No..~...~..~.~ ....... .~....--~-- Application No. ~c~'~ ~ Disapproved a/c ..,/......:~.~....~.~.j..~:;,,~ ...... .~..,~x~ .............. ~ ..... (Building I~pector) APPLICATION FOR BUILDING PERMIT Date ....................... .~'..~j~ ........ .~..~.~. .......... ,19 ~'.~ ...... INSTRUCTIONS a. 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 property must 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 regulations. (Signature of applicant, or name, if a corporation) ...................... (Address o~ applicant) State whether applicant is o~n,%r,~lessee, agent, architect, engi'neer, general contractor, electrician, plumber or builder. ................ ............................ Name of owner of premises .../..?..6~.k~.........~L..~..~.~?..'~K~¥~. ............................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) ]. Locotion of land on which proposed work will be done. Mep No.: ........................................ Lot No.: ........................ - '-" ..... ,4- Street and Number ..... /z~./...~..-~'.....~.~..~:... (/..~..~ ~//~ - Munici~li~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: .. .......................................................................................... b. Intondeduseondoccup*ncy ...... ~..~..~. ................................................................................................ 3. Net+re of work (check which applicable): New Building .Z~.~..b~...... Addition .................. Alteration Repair .................. Removal .................. Demolition .................. Other Work (Describe) 4. Estir~ated Cost ...~...~..?.~ ...................................... Fee (to be paid on filing this application) 5. If d~velling, number of dwelling units ............................ Number of dwelling units on each floor ~.~t~..~ ........... If g1~rage, number of cars ....z/./~.~. ......... 6. If ~usiness, commercial or mixed occupancy, specify nature and extent of each type of use 7. D m, ens ohs of existing structures, if any: Front ............................ Rear ........................ Depth k Height ........................ Number of Stories Dim'ensions of same structure with alterations or additions: Front ....................................Rear Dep'h ................................ Height ............................ Number of Sfories ................................ 8. Dimensions of entire new construction: Front ...~..~../. ......................... " Hei! iht ..... .~..( ......... Number of Stories .....-r~. 9. Size of lot: Front ............ ~. ............. Re ............. 2 ................. Depth ............... ~., ................ 11. Zen or use district Jn which premises are situated t2. Doe¢ proposed construction violate any zoning law, ordinance or regulation? 13. Nam,'e of Owner of a?e of Contractor Pho e i PLOT DIAGRAM L.ocotb clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions property lines. Give street and block number or description according to deed, and show street names and whether interior or corner lot. L,,-r 5'/ 4lo STATE OF NEW YORK, COUNTY DF ................................ .................................................................................................. being duly sworn, deposes and says that he is the applic I'~Name of individual signing application) above nerved. He is the (Contractor, agent, corporate officer, etc.) of said o~ffner or owners, and is duly authorized to perform or have performed the said work and to make and this application; that oil statements contained in this application are true to the best of his knowledge and belief; that the wbrk will be performed in the manner set forth in the application filed there,~';th. Sworn to I~efor,~ me this .,,* ' ~/*] ~ // .......................... ..................... . ....................... .... Note ry Pu~l~~.... ~..~ounty ~~e of applicant)