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Home My WebLink About8401-z ~ · : BUILDING PERMIT HS PEP.MI MUST BE EPT O T ~ . ,. 3/ .... ~ N HE PREMISES U~TiL ~ULL ~L~ION OF THE ~O~K AUTHORIZED) sioi z " ~o,0 ..................... ~.....a ............. ~.:., ,~..~, hereby gran ' to; ' - SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY Appli ' ~ ~ '" ' - 5. Subdiv. 1. cant '_ ~ ~ ~ ~ Phone - , ?,,, ~ ' ' ~ ~ - 6 Section Address " · ~ ,. ,,~ ~ . 2. Property Locatign ~ 7. Lot Number ...... 8. Private Wel~ 'l]ag hip ~i e ' ' ~ Towns ,~ -~ ,, ~ 9. Public Water 3. Public Water Company Name Distance to main 4. Lot size: Width " ,feet Length ~''~feet' 10. Sewage Disposal System: (For Health Services Dept. Use) A. 900-gallon septic tank: Precast Equivalent Block B. Leaching pools: Number of pools ~ Precast Block k-~/Special__ ll. If private well, fill in the fol- lowing blanks: A. Tank capacity. L~ ~- gallons B. Pump G.P.M. ' C. Total well depth D. Depth to ground water E. Amount of water in well 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 '/ "~ Signed 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. APPROVAL DATE ~ ! ~'- SIGNED S-15 Rev. 4/1/73 ...... _ ,-~,/,, BUILDING DEFARTMEHT.~,~-- ~, .. Y. ~..~~. ~.,.~ .......... ~...A... ,,~ ~ __,,~'~~..L ....... , ~,~ ................... :. ......... .~..... ,~Z~ ~,~,,,o .......... teL..~ ....... .......................... : ........................ ........ .. .. ......... ~a-.~;i ........................ .: .... b. ~lot plan ~h~in~ I~tion o{ lot ~nd o{ buildin~ ~ pr~mise~, relationship or~as, and oivi~ ~ det~il~ description o{ I~o~ o{pr~ mu~t be drown ~ th~ die, mm which c. ~ ~o~ c~r~ b~ thi~ ~li~ati~ m~ n~ ~ comm~nc~ befor* i~uonc~ d. H~n o~r~l o{ ~i~ ~lic~tion, ~ 8uildin~ Ink, tar will i~u~ ~ ~holl ~ k~t on th~ premise~ ~v~ilabl~ {or inaction th~h~t th~ ~rk. e. ~o buildin~ ~h~ll be ~cupi~ or u~d in whol~ or in ~ {or ~n~ pu~ whoever until shall have been gmnt~ by ~e Building Ink,tar. APPLI~TION IS HEREBY ~DE to the Building ~panment for the i~uance of a Buildi~ Pe~it puget Building Zone O~inance of the T~n of ~uthold, Suffolk Count, New York, and ~her ~plic~le Regulations, for the constru~ion of buildi~s, additions or altemti~s, or for ~al or de,lite, ~ h~in ~H~. ~e applica~ agr~s to comply with all a~licable la~, ordinances, buildl~ c~, h~i~ c~, admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant, or name; if a corporation): ....................... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ....... ==================================================================== If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No .... ~ .......... Electrician's License No...~ ..... /o~o f ~7/- /- ~ Other Trade's License No ............................................... ~ ~ 1. Location of land on which om~osed work~ill be dooe. Map No.: .................................... L~ hl~ .....~.....~J~--~... Street and Number .... ~....F~.....c~....~..~...~.....,t~?..../~....~......~..'~.~.~.~..~....~ Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. E×isiting use and occupancy ................................................................................................................................ ~~ b. Intended use and occupancy .........................~./..~ ................................................................................ 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work ..................................................... 4. Estimated Cost ......................... ...l~>.,...:..,,d~,,. ................. Fee ...Z..~,..,~..: .............................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ........... ./. ............... Number of dwelling units on each floor ...... /. .................... 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 .......... ..~...Y...i ................. Rear ....,~....~...: ................ Depth ....... ~.~..~ .................. Height ........... ~..~..[. ......... Number of Stories ............. -/ ................. 8. Dimensions of entire new construction: Front .......... .J.~'..O.:/,.~ ............. Rear ..... ..~.....~.~ .............. Depth ...../.~2'..;..V.~ ....... Height .................... Number of Stories ...................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........... ~...~I.~V..../~..~. ............................. 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ........ ~.~.~Will excess fi)y~ed free, premises: (~.~._Yes ( JO No 14. Name of Owner of premises .....~~~/~.~,, ' "_'~s ~/~-~.~Address ~"~'1gx''~''~~/ze-~ ~ ....... Phone No..~.~...~...~..~..~...~..O Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor ............... .~....~6~.~..~/~... ...................... Address ................................ Phone No ....................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fram property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. 07/- f - / ~)'7/- l- 3 STATE OF NEW,,,vopJ~. . COU NTY/~ .~....~.~. ~ ~ ,~) ~ ........ (Nome of individuol signing c~trec~ above nom~. He is the ................................................................................................................................................................................. (Contractor, agent, co.orate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke and file this application; that all statements contained in this application ore true to the best of his knowledge and belief; and that the work will be performed in the manner set fo~h in the application filed therewith. Swom to,elam me th~s .............................. .............. ......... ........................................... /1 . /~///~ /~~ (S~gnature of applicant)