HomeMy WebLinkAbout7761-zFOR31 NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificate Of Occupancy
/
conforms substanti~ly to the Application fo~ Building Permit heretofore filed in ~his office
dated ......... ~:~. ~., 1R~.. pursuant to which Building Permit No.~
dated ....................... , z~: ..., w~s issuea, ~a conforms to all of the
merits oi the applicable provisions of the law. ~he occupancy ~or which Chis certificate
issuedis/' ~[VA lc 0~. f 2 {~tg ( ~'L 6,
............................... ................................
(owner, lessee or ten.t)
of the aforesaid building,
Suffolk County Department of He.th Arrrova~ .~eS.~..? .(.~ ~ ?.. '~' ~ ~.
~OUSg ~gR .... l.q ~ t .0... Stree~ ...... t ...................................
........ :.. ..... '~ ...~...[ ...... ~ ......
Buil~i:~ Ia~p~tor
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N? 7761 Z
Date ......................... }/%aX'.~h....2.0 .......... 19.~..~...
Permission is hereby granted to:
R~b.t..~ar.....~.C.C.l~f~d.M. tz ..................
................ ..s..o..u...t.~p.~.a.. ............................................
~o ~.~.~.a....~.e..~...,°.~..e....ta..m...t.~...~..e...z.~.~ ......................................................................................
at premises located at ...... .~4~-..~.~ ....... ~enl~ee~t;~..~ ..............................................................
.......................................... I,a~vel ..,~,~ ~.. ~c...Lo~a~..C.~.~ek..,O~'.~.ve ....... S~u.~hol~ .....................
pursuant to application dated ................ [qa-I'......20 ................. !.:.,, !9..~., and approved by the
Building Inspector.
Fee $9.~...~[0 ............
Building Inspector
SUFFOLK COUNTY BEPARTMENT OF HEALTH SERVICES
Health Services
Reference Number
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
1. Applicant ,.,c ,-,' :~ % ,.,: Phone 7~ ~
Address
2. Property Location ", 4, -:-~ ~,, -
Village ']~ ," ; '
' , , Township ~.~r,,-
3. Public Water Company Name G¥;:,-. ,, ':
4. Lot size: Width ' '~ feet Length xx a feet
10.
ll.
Sewage Disposal System:
A.(/~gallon septic tank:
PrecePt. ~ [quivalent Block
5. Subdiv.
6. Section
7. Lot Number
,8. Private Well
9~ Public Water
Distance to main ~
(For Health Services Dept. Use)
B. Leaching pools:
Number of pools~ ~
Precast~ Block _Special
If private well, fill in the fol-
lowing blanks;
A. Tank capacity]~_~llons
B. Pump G.P.M. ~
C. Total well/Jepth
D. Depth to ground water
E. Amount of water in well
The undersigned CERTIFIES: "Construction of authorized: installations w~ll be'i~n)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-
Wi~Jq, 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.
^PP.OV^L .ATE
S-15
Rev. 4/1/73
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