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HomeMy WebLinkAbout4792-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at../.~..~.0.. ~.~..~, .~.~.~..~. ~'...~. ~eet Map No. ~'/~' ~ ~ Block No. "' .Lot No. ~ 7 ........................ conforms substantially to the Application for Building Permit heretofore filed in this office dated .............~...~.~..~[., 19.?.~. pursuant to which Building Permit No. dated ~' ~Yt,',¥' 19'7~., 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 ....... .~..~. ~ ...... .,~..~..~.~ .I. ~..y. ..... .~...~..~'..~..Z,./..A~...~-.. .................. The certificate is issued to..~..~...'ff.~ #:..h/....~....~....~..~..~. .... . .~.~..~. ............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .~.~..~..~.~...~..~ ..... .~.f~..Z~...../(~.~..~. Building Inspector FOB, b[ NO, '~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT CI'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N.o 4792 Z Permission is hereby granted to: .... &j~..~.... ~t¢..,~/et~t~e~ · &.. &=J-.llee ..... ~ ...... ~=zm~se..Z~r ......................... ......... J.o -M,p..h~ee ........... '11-~/* .................. to .,jj,~.. ,~¢.. m~ ..£~r,~¥..A~e ~,,t~ ~ .................................................................................. at premises located at ~ ~ 1~&2,~ &J,J~ ~ll'~&t,4ll I/J .~l.J,t.G.t.~e ~L)t .......... ¥,J ;~ .t. lJp. zm~ ......... 11.~. ................. pursuan¢ to application dated .................... ~IIJlL ............. ~ ............. , 19..~C1., and approved by the Building Inspector. 'JOe'Y) Fee $ ........................ S-9 SCHD SUFFOLK COUNTY DEPAHTHENT OF HEALTH Date Bldg. Permit No. ~ 4?922 ~0 WHOH IT HAY CONCERN: The sewage disposal facilities for a structure at g/s Saltaire Way, 175' S/of Soundview Avenue, Mattituck (Give deed location) located have been inspected by this department and found to be satisfactory. District Engineer RECEIVED 19ltt NOV -~ A/~ 9:22 IEPARTMENT OF HEALTH R)VERHEAD FOLK COUNTY DEPARTMENT OF HEALTH DISTRICT One Old Indian Head Road Co.ack, New York 543-1116 H.D.Ref. No. 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 Mstth~vb 3-Subdiv.~alUire Address West I81iP Phone~9*6Sl6 i-Section No. 2-Name of Builder~l~. ~.: I~. Phone~5-Lot N~ber Address ~A~ I~l~ ~w. T,lim ~ 6-Bldg.Pe~it No.~ 7-Sewage Syst~ imstalled%y '~F~'~ Phone ~T Address 8-(a)Deed location of property H~s ~l*sl~ WsF 1~1~ I~e~ (b)H~let or Villaie ~ttl~k 9-Septic tank-Gal__L ft.~ ft.Liquid Depth ft. 10-Cesspools-(a)No.pools I (b)Blocks bel~ imlet-1)~2)~3) (c)Block size-Llin.~ [ im.~ [ in.(d)Precast pool__(e)l~ 3__ (f)~__ft.__fln; Di~ ft.__in.(g)Fimished grade to cover ~ ft. (h)Backfill Materia~. ll-~ater Supply: Public Syst~ ; Private ~ell If Private~ the foll~iml questions are to be answered: 12-Private ~ater Supply Syst~ installed by ~ls ~11 ~tll~ Phone~ Address 13(a)-Total De ell ]~ (b)Depth to Static Water Level 14-Diameter of well pipe ] 15-Name of ~boratory ~ e a ~ 17-Date ready for inspec~i6n 16-Method of Dlsinfection__~_~~h tO lO~al. Water The undersigned CERTIFIES: Above systems have bee~ constructed and are in compliance with the Suffolk County Health Department's cu~ffent S~/ndards. Bulletims and Amendments thereto. 18-Date ~igned 19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. ) 0 STREET ~'~ · · .............................................. ............. FOR HEALTH DEPARTMENT USE ONLY Inspected by?ff__~f__~ Date Based upon the info~ation s~a~ed above, satisfactory func~ioning of the above sys,.s can be expec,ed with proper maintenance~ar~ NOV 3 0 ?g70 *pproved S-5 Instructions for 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 1. O~ner's name and address - if o~mer 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 8ubdivimionmap. 4. Section number of realty subdivision map. 5. Lot number of plot on which disposal unit is constructed. 6. Buildin$ permit number assisned by the Buildin$ Department. 7. Name of person or firm who actually constructed the sevase disposal facilities. 8. (a) For example: 8/8 Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated area in township), for example: East Horiches. Villase (incorporated area), for example: Horthport. (c) To~uship, for example: Brookhaven, etc. 9. Give inside lenEth and width in feet. Liquid depth is measured in feet from bottom of outlet pipe to bottmn of tank. 10. (a) State number of pools. (b) State number of blocks below inlet pipe for each pool. (c) State lensth, width, and heisht of cesspool blocks in inches. (d) Indicate by check if precast sections are used. (e) Give number of leach- ins sections per pool. (f) Give heisht and diameter of each leachin$ section. ($) Glv~ depth in feet from finished srade to cesspoo~ cover. (h) Describe backfill material used. ~l. Indicate by check if water supply is public or private. 12. Name of person or firm who actually Installed the water supply facilities. 13. (a) Give depth in feet fro~ top of well pipe or casin$ to well point. (b) Depth in feet from to~ of well pipe or casin$ to water level in well. 14. Inside diameter of well casin$. 15. Name of laboratory performin~ the examinations. Describe method of disinfection, for example: quart of laundry bleach in ten sallons of water poured into well and alloyed to stand six hours. 17. State date on.which installation will be ready for inspection. 18. Application must be sisned by builder or owner. Sisnatures of subcontractor, superintendent, etc., will not be accepted. 19. Indicate location of Water & Se~erase Facilities with accurate dimensions on sketch. , t~ ~ ^. V;~. TOWN OF SOUTHOLD ~ BUILDIHG DEPARTMENT ~/~/~ * TOWN CLERK'S OFFICE ~0/~ (~ S~TH~D, N. Y. ....... ......... .o ...... .... A~r~ed ...M ................................ 1~ ........ ~.rmit No ......... ~..~. 1. ~ ,~,~,~[ ~-, ............................................................................... ~.~.....:....~.. ~/~ '~r/o~ / / ' ............. ............. ....... .......... APPLI~TION FOR BUILDING PE~I~ ~te .....~..~ ......................................... , 19.~. ...... ' ' INSTRUCTIONS a. This application must b~ completely fill~ in by ~ewriter or in ink und submitted in ~plicate to t~ Buildi~ In~r. b. Plot plan ~owing I~ation of lat and of buildings on premise~ relationship to odjoini~ pmmj~ or ar~s, o~ givi~ a d~ailed ~ri~ion of I~out of pro~ must ~ drawn on t~e di~ram ~h c. ~e work c~er~ by this application may nat be commenced b~fore i,uance of Building Permit, d. Up~ ~p~ol of this application, the Building Inspector will issue a Building Pe~it to the ~ppllcant., ~ch ~it shall be kept on the premiss available for i~pection throughout the p~ress of the wo~. e. ~o building S~ll ~ occupied or u~d in who~e or i~ ~ort for any pu~ose whatever unti~ a Ce~ificate of ~c~ncy shall h~e ~en gmn~ by the Building Insp~tor. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pumuant to the Building Zone Ordinance of the Town of Southold Suffolk County, New York and other applicable Laws, Ordirtances 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, housing code, and regulations. (Signature cf applicant, 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 owne~f~premises ........ J~IJJJJI~..~J~..MIIJ. AIIL.II~t ............................................................................................... (Name .....an/ ~ '" d title'o~corporate officer) /~ ~(~'~,e,~t ~,-,m~,,~- ~ 1. Location of land on Which proposed work will be done. Map No.:........~ ....... .. ............... Lot No.: ..... ~ ............... Street and Number ...l~/.l~...~l~..~..~..~.e...~l.~...~..~...~l~.~ ............................. 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy IIJI b. Intended use and occupanc,' ......IJ[~lg...~.~..~.J.~..~.J..J.....J~ ..................... ...................................... 3. Nature of woik (check which applicable): New Building ......~... ........ Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ...................................... 4. Estimated Cost ...... .~[~(~1~. ................................. Fee ............ (to be paid on fi!lng this application) 5. If dwelllng, number of dwelling units .lll..I .................Number of dwelling units on each floor ............................ If garage, number of cars ....... J..IIILCllI~II ................................... 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 ...,~9..e.*n~". ..................... e . Rear ....~u~...e~J ............. Depth ..... ~l~. .............. Height ....~.0..". .... Number of Stories 2 9. Size of lot: Front ....... ].~ ............... Rear ............. ~.l~. ................ Depth .............. ~ ............ 10. Date of Purchase ..... ]I~]L/~I~. ...................................... Name of Former Owner ..... .~........I~.~.~.. ........................ ! 1. Zone or use district in which premises are situated .................................................................................................... 12. Does proposed construction violate anyzontng law, ordinance or regulat on:~ . it. 13. Name of Owner of premises ..llll~llll~J.&J~J.J~l~...Address ...~.~,~lllil41ltlL.&~lll~ ....... Phone No, ~... Name of Architect ' , ........................... Address Illll~ ~1~141. I1~ Phone No .................... Name of Contractor /,1~.1~"I1~.11111~,.~ ......... Address .~l;L~..~Jll311~ll~.il.][~...,.. Phone No..~IL[~. PLOT DIAGRAM Locate cleori¥ end distinctly all buildings, whether existing or proposed, and indicate oil setdxick dimensions from property lines. Give street and block number or description according to deed, and show' street names and Indical'e whether interior o, corner lot. STATE OF NEW YORK, J~... COUNTY qF ...I.JZel;k .............. ' · 'I~II~"RJJ~IJ"~"; ~Jll~lJJJ~'" '(J~J~" '..~.*. '..~.e: ....~.. · .*. ). ............ being duly (Name of individual signing c~oPlicetion) above named. He is the ................. ;.~,t ...................... j~ ...................... j .................. (Contractor agent, corporate officer, etc.) of said owner or owners, and i~ duly authorized to perform or have perforrq~¢ the said work and to make ond file this application; that all statements contained' in this application are~true f0 ~j ~'best of his knowledge and belief; and that the work will be performed in the manner set fqrtl~ in the application f~lle~f mr~ith. Swam to before me this ":: .................. NotarY Publio, State of New~'Y~t No. 52-892~125 Quallflecl in Suffolk Count~ ~Term Expires, March 30, sworn, deposes and says that he is the <~1114~ / 104, ~ssumed ~/u~ 0 0 SUFFOLK COUNTY DEPART~MENT ~F HEALTH A?~,~CATZON FOH AF~OWL TO CONSTHUqT P~A?~ S?WAG~ DX$~SA~ S~S~ Approval to const~ct said systems' 'iS requested,pertinen~data here~th: Date ~y 28, 19;O i-Applicant ~w Bro~. ~o~, Inc. ,Phone ~ ~0~06-Sub div Saltaire E~ate~ Address Sunrise HIs~y~ Ioltp Terrace ~. , 7-Section 2-Detailed property location ~/8 Saltatre ~. l~S~$f 8[Lot No . 2'~I ~ $0mndv~$w Ave.. ~lSuck To~ Seuk~old ~ I'9 P~ivate' wel~ I ~el~ 3-~blic ~ter supply name None I Distance to n~arest main Several Miles 4-Lot Size: Widt~OO ft. LenEth 20~i ft. (also ente~ on~ center plot plan below:) 5-~elling: Single Family ~ l T~ Family? / /Ce[lar~ ~la%? / I Crawl S~ce? / / lO-Pro,ed system: Septic ~ank / /Precast / /Cess~bls ~Shall°w pools / /othe~/i. / ll-Sep~ ta~inside dimensions: Vol~e i [Gals. Length ft. ~idth ft. Liquid dept~ft. 12-Pre~t ~ions: / ~Number/ /Square Ft. Cesspools: Block sizeL~$ incs.D~ins. H ~ ins. Total b~c~J~w in,et. ~1~ ~2~$3 i ~ T;~ ~LOT PLAN Ca,city 4~Gals. Street Data Feet Top 0 Soil 2 Sand 4~ & 6 Cravel 8 10 12 f4 ~6 Wa~er G.P.M. 5 VACANT + can be installed on this Plot. Date I 0 Signed ev s.> EXCAVATION o No~th The Undersigned CERTIFIES: "Construction o£ authorized installations will be in accordance with the Suffolk County Health Departments' ~u~rent Standards, Bulletins, a~ amendments thereto, covering Private Se~g~p~yst~s". Date ~/~/70 Signed I ~4rOr ~? B~iider;~ FOR ~AL~H DEPART~NT USE ONLY. Based on the mnfo~at~on~re~ented herewith, it is the opinion of the Health De~rtment~ that an adequate and sa$~sfacto~ Se~ge Disposal System APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate i-Means Owner or Builder. Address to which mail should be directed. 2~.Means detailed description of property location, together with street name and distance to nearest intersection of ~ain thorofare, also Hamlet/Millage & Township 3.Enter name of Public Water Supply District~ together with the distance to their main. ~.Enter Length and Width of Lot under appropriate heading, also enter these dimensions on center plot plan shown on the face of this application. ~.Dwellings: Check-mark "V" items applicable to the proposed new dwelling. ~.Name of sub-division ?..Section Number 8..Lot Number 9..Private well: Enter "No" if Public water supply is available. Enter "Yes" otherwise. P_I~OPOSED SYSTEMS: Answers to Items number 10, il, & 12 please consult the S~ffolk County Health Department's Standards, Bulletins and Amendments for Sewage & Waste Disposal Facilities. i.e., Part II-Residential Sub-surface Disposal Systems covering Cesspools Part III " " " " " " Septic Tanks Part IV " " " " " " Unusual soil conditions Part V " " " " " " Shallow Leaching Pools P_.L~.T PLAN: The following information is required concerning the Applicant's Lot: Lot size-Length and Width in feet to be indicated at the Lot lines of the heavy lined square in the center of Plot Plan shown on face of this application. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 50 feet of Applicant's Lot lines, must be shown on the plot plan also. Wells and Cesspools now on adjacent lots must be shown on the Plot Plan together with the distance to the Applicants proposed Sewage Disposal Systems and Well. Where no Buildings exist on adjacent lots, state "Vacant" on the plot plan. Streets adjoining applicant's lot to the right~ left or rear, enter street name, _WELL LOCATION: To locate the well & sewage disposal systems on Applicant's lot, the following Standards must be observed: Well-100 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-I0 feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Well-40 feet minimum into ground water for well point Well-4 feet 6 ins. minimum below grade to well head and lateral water pipe _CE.S. SPOOLS LOCATION: Upon determination of the Sewage & Waste disposal "type of systems" required, the following Standar~ds must be observed for the location of same: Cesspool-10 feet minimum distance from lot lines to center of cesspool Cesspools exterior must be 100 feet minimum distance from nearest well Septic tank exterior must be 75 feet from nearest well Cesspool "Center" must be 12 feet minimum distance from nearest water line Cesspool "Center" must be 15 feet from house foundation Cesspool exterior must be 50 feet minimum distance from surface Waters, ~-.¥~' "$~e~a~S~~ Cesspools must be 20 feet minimum distance from large trees~ ~,%~" ~\ Cesspool center to Cesspool center must be at least 16 fee~' ~i ~ ~ Cesspool cover top to grade must be held to minimum of 1 food t~ ~mu~m ~ fe~ Bottom of Cesspool to ground water must be held to minimum of lk~oot~\~ ~1~ ~ -[-- L -[ v A ? F .I 0 N RES. FOR.,, LOOATION~.. ISLiP TERRACE, NEW YORK DAVID R. BROOKS' .A~CHIT, ECT :[ -' :,'"- ...... FL 00!7 P L ,^, N 'DAVID R~. BROOK5 ARCHITECT } ,W._ ooj2 *%, ...... DAVID R BROOKS TERRACE,, ['~EW YORtC ' · ~ /,/.x,"~ ] : ' ' · ' '?, ".' ~OCATION~ PLUMBING / \ ~ J ~/-0'l L .,FO U N D -A--~-!