HomeMy WebLinkAbout8308-z FOBM NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 8308 Z
Permission is hereby granted to:
'- at premises located ata~m-.~41~.~ .........................................................................................
................................................... ~*,~:~ ......... ~.~. ........ :.:....:.....,....; ...............................................
pursuant to application dated~,. ....................... ]~ ...... :fig" ........... , 19:. , and approved by the
SUFFOLK COUNTY DEPARTMENT OF HEALTH
Health Department
Reference Number
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
1. ApplicantJ, (~ ,y_~,./·~ ..... J Phone..' ~-
Address / ,w ~ ~ , .,-,'~ ~. ' '.
2. Property Location ' ~ ~',~,. ~ ..~ /~ ?
~ Township ~ ~/~_ ~
Villag~ ~ ~ ~/ ~
3. Public water Company Name
4. Lot size: Width ~ .~u feet Length / ~, feet
5. Subdiv.
6. Section
7. Lot Number
8. Private Well
9. Public Water
Distance to n~in
10. Sewage Disposal System:
(For Health Dept. Use)
11.
A. 900-gayon septic tank:
Precast~ Equivalent Block
B. Leaching pools:
Number y pools S
Precast /Block Special
,If private well, fill in the
following blanks:
A. Tank capacity ~ ~ 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's 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 HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the
opinion of the Health Department that an adequate and satisfactory Sewage Disposal System
and Water Supply can be installed on this pl~ot. · ~) , ~
S-15
Rev. 4/1/73