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
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F .I 0 N
RES. FOR.,,
LOOATION~..
ISLiP TERRACE, NEW YORK
DAVID R. BROOKS'
.A~CHIT, ECT
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FL 00!7 P L ,^, N
'DAVID R~. BROOK5
ARCHITECT
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......
DAVID R BROOKS
TERRACE,, ['~EW YORtC '
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~OCATION~
PLUMBING
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