HomeMy WebLinkAbout7746-z FOI%M NO.
TOWN OF $OUTHOLD~
BUILDING
TOWN C!.~r~K'S
SOUTHOLD, N.. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UN'ltL FULL
COMPLETION OF THE WORK AUTHORIZED)
'Permission is hereby granted to:
F&,m-~v~..,~t~'~&~:~g'"'~ o'"" ~,:/~'"~'o'.,b~ "&" 'C2o.~ :L e ~ic~ol~
..... · 1-~.~ .... ~'.~.n...h.~...Dr .................................
..... f.......~c~'~o~,~e ............................................ :'
~o ..b.!.~.i...]:~L .L~z~...o~...-Car~ 1~..- ~:.¢e2.:~£n~ ........................................... ; .........................................
at~oremises located at ~],/~L.~';~It~,..:'/.~(~'~...~'e ........ ~ ..........................................................................
....................................... ~ ....... .'.:Ic.~;...~,:;~.~.~;i~n. ...... i,:.~.~:.~ ......................................................................
pursuant to application doted ........................;,!~.~eh' ....... 't'(~ ....... , 1~.~......, and approved by the
Building Inspector.
Fee J.L~,~..~. ..............
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
Health Services
Reference Number ~,~'- ~'~J--~O
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
'- :~ ~ ~ ~ Subdiv.
Applicant ~-A,~t~,~ ~,d, ~L[~ (,~ Phone ~,~ ~{~ 5.
1. Address i~ ~nA~ ~AK? ~P~ ~i~C~j~dE..~ ~.~.6, Section
2. Property LoEa'ti6n'~-~F a ~?~j~']~ ~, q~ ~/., ~^~i~J. Lot Number
ViT16ge Township ~'~,e '~'~,''~ ~ 9. Public Water
3. Public Water Company Name -,- Distance to main
4. Lot size: Width %?[ feet Length. !S:o feet
10.
Sewage Disposal System:
A. ~O0~gallon septic tank:
Precast ~/.[quivalent Block~
B. Leaching pools:
(For Health Services Dept. Use)
Number of, pools
Precast ~;} Block
Special__
ll. If private well, fill in the fol-
lowing 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 ~i)
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.
':"' f'-~ SIGNED
APPROVAL DATE
S-15
Rev. 4/1/73