HomeMy WebLinkAbout7674-zSUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
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3.
4.
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ll.
Health Services
Reference Number
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
Applicant ~q
Address
Property Location
Village ·
Public Water Company Name
Lot size: Width,, feet
Phone -,; ,, : 5. Subdiv.
6. Section
,:: ''~ - :- ~T :7. Lot Number
8. Private Well
9. Public Water
Distance to main
Length.//> ~ feet
Township
Sewage Disposal System:
A. gallon septic tank:
Precast~' Equivalent Block
B. Leaching pools:
Number of pools ~
Precas Block
If private well, fill
lowing blanks:
Ao Tank ~apacity " , gallons
B. Pump G.P.M.
C. Total well depth
D. Depth to ground water
E, Amount of water in well
~pecial__
in the fol-
(For Health Services Dept. Use)
The undersigned CERTIFIES: "Construction of authorized installations will be in accordance
with the Suffolk County Department of Health Services' current standards thereto." This
application will be valid for one year from the date of approval indicated below and may
be renewed if a current local Building Department Permit is in effect.
Date '/ ~..' - , SI-ned '~
......... Z'---_~ ...... L ................. = ' / "~ f ,~ ~ -~, .
....................................... =================================================
FOR THE DEPARTMENT OF HEALTH SERVICES~ USE ONLY. Basedlon the ihformation presented here-
with, it is the opinion of the Department of Health Services that an adequate and satis-
factory Sewage Disposal System and Water Supply can be installed on this plot.
APPROVAL DATE p'l" l r SIGNEO
S-15
Rev. 4/1/73
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
Health Services
Reference Number
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
1. Ap pl i c an t ~,/r~c~/~c Z~w q- .~a ~/~
Address ~',~ ~j
2. Property Location
10.
11.
5. Subdiv.
6. Section
7. Lot Number
8. Private Well
Village ~7-~uc~c ~y Township
Public Water Company Name ' ~/o~
~/ 9. Public Water
Distance to main
Lot size: Width~o feet
Sewage Disposal System:
A
A. /O0~gallon septic
tank:
Precast~ ~[quivalent Block
B. Leaching pools:
Number of pools '}
Precast {~ ~lock Special
If private well, fill in the fol-
lowing blanks:
A. Tank capacity, f~ gallons
B. Pump G.P.M. /~
C. Total well depth 6[~
D. Depth to ground water .2a
E. Amount of water in well ma
Length. J %t~feet
(For Health Services Dept. Use)
The undersigned CERTIFIES: "Construction of authorized installations will be in accordance
with the Suffolk County Department of Health Services' current standards thereto." This
application will be valid for one year from the date of approval indicated below and may
be renewed if a current local Building Department Permit is in effect.
FOR THE DEPARTMENT OF HEALTH SERVICES' USE ONLY. Based on the information presented here-
with, it is the opinion of the Department of Health Services that an adequate and satis-
factory Sewage Disposal System and Water Supply can be installed on this plot.
A PROVA ATE SI NE
S-15
Rev. 4/1/73
DESCRIPTION
MATERIALS AND
SPECIFICXlONS
*ubtraction{ or addition* ore made before signing, make
I I
I1~ any changes, subtructlans or additions are made after
signing of ¢ontra~t have such modifications put an all sets
in existence and have them initialed. Have all price
changes in agreements in writing. Following these simple
rules, there is little chance for any future disagreements
between tau and your builder.
similar (F.H,A,, etc.) requirements and are thoroughly
familiar with the commitments they are signing.
The instructions on the NEXT PAGE are important to
read~ Ihey enable you to complete the Description of
Materials.
BELOW is a diagramatic plot plan. Fill in the spaces to show the
d~mensJons underlined, the north arrow, the street name, the distance
from the corner of your property to the nearest street intersection
(and the name of that street). If a corner plot, also show the side
rear of lot-
('~"feet if corner lot ) I
frontage of 1at
street name
0
~orth
arrow
distance to corner
(¥feet if corner Iotl
lot lines
FOL[
, I
plans are reprin
each page. To
plan, take the n
of each.sieet.
of the house design, these
ed (in reverse) an the back of
Facilitate use of the reverse
ain dimensions fram the front
design number sheat no.
DRAWN BY
APPRO¥£D BY
designI ~-~ ~-,-~7 number shebf ~. ~ ~-~ no.
DRAWN BY
APPROVED BY.
design number sheet no.
I ~-~.~ ~-----
DRAWN BY
APPROVED BY
design number
she6f no.
12.
1
r
RUDOLPH
design number I sheet no.
I c.':, ~L7
· ~ ....... ~, PROVED.~.,...ac NOTFr~ ' - '
..........
........... , , . .... ...... ~ BEFO~ C~VERNG~ELNE "~ ~
, . , , ~ ' ,', ~ , ,., . ~ - , , ' , ~ - , ~ , ~.,,~A~,~HEN JOB QDM~LETED ,' ~ ' ' ~ ' '- ,' - ~ ~-': , ' ~ , , '. , --', "' '~q