The URL can be used to link to this page

Home My WebLink About12620-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. Z12797 Date Sept. 20 84 THIS CERTIFIES that the building One Family Dwelling Location of Property 405 Smith Dr. South hSds~ ~/oi ..................................... 8'9 'u'~'h° ld Street ......... hi~iel County Tax Map No. 1000 Section 076 ...Block 02 .Lot 025 Subdivision Goose Neck 128/129 ............................... Filed Map No..1.6.6.3....Lot No .............. conforms substantially to the Application for Building Permit heretofore fried in this office dated Auq. 30 19 .8.3. pursuant to which Building Permit No. 12620 g dated ........ S.o.p.t.. ......1.7. ....... 19 .8 .4., was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... Private One FamitX Dwellin~ The certificate is issued to .......... D'Q '~'D'"TE' 'D' '~>~tn'o),'l~,~sde'~r't~e'a't) ...................... of the aforesaid building. Suffolk County Department of Health Approval ...... .1.3.-.S.O. 7.1.5.1. ......................... N655756 UNDERWRITERS CERTIFICATE NO .................................................. Rev. 1/81 Building Inspector FOF,~[ NO. 9 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PER~IT CrHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 1~0 z Permission is hereby granted to: .... .~ ........... ~...~. ............ ~: ........ .~. ............... _ ..~~ ........ ~.., ...... ~.;.~.; ......... ~ ........ 7','" .~ ~ ':'~.'-~. ~' ~"%';' .... ~'~ ....... ~'"'~'i;~ et premises located at ....~....0...~......~....~..~..~ ...... ..~...~...~. County Tax Map No. 1000 Sd~~..L~....~...~ ....... :~.. ............. , 19..~..~ and approved by the pursuant to application date Building Inspector. Building Inspector Rev. 6/30/80 FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall ,~uthold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitte~to the Building Inspec- tor with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3, Approval of electrical installation from Board of Fire Underwriters. 4, Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Nomconforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of peoperty showing all property 'lines, streets, buildings and unusual natural or topographic features. 2.Sworn statement of owner or previous owne~ as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling / land use -- ~re-]~×is f~lng C. 0. $15.00 3. Copy of certificate of occupancy $1.00 Vacant land C.O. $ 5.00 Date ......... ~, .. New Building · · Old or Pre-existing Building Vacant ........... · ........... Land ............. Location of Property .. ~,~, ,~,. . ,~... ,~r~, .~,~, ,~., ,~.,~, House No, Street Owner or Owners of Property .......... County Tax Map No. 1000 Section ...1~.~.. .... Block ...(~[~..<c~. Lot... ~_..~. ....... Subdivision .... · '~' 'o'(2'J'c;...../~?.~.~'. ........Filed Map No. '~/. ¢.~'..~...Lot No...I,~..~//?..~'. PermitNo. ]~.0..~.. Date of Permit ~/l~/~.g~ ant .... ~ ~- ....... Applic Health Dept Approval Labor Dept Approval Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate Fee Submitted $ .~.-~. ....................... Construction on above described building ap~Lp~applicable codes an~-~u~i--~oo ~ '*~ ~1o~ Applicant... Rev. =i-0-10-78 1000378 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY ~' 8S JOHN STREET, NEW YORK, NEW YORK 1OO3e ~.te Auguwt 20, 1984 253059-84 1 'p, llca,ion o. on;ile N 65575 THIS CERTIFIES THAT only the etec ~rical equipment as described below and int~duced by t~ applicant named on the ab~ application ~u~ber ~n the premlse8 of '~eodore Dowd~ Smith Dr~ South~ Southold, N.Y. inthefollowinglocation; ~ Basement ~ i,trt. ~ ~,d rt. aCtig~ outBide s~tlo. Block Lot ~., .x.,.i..d o. AUg ,~ 6, 1984 ~nd /o..d to be in compliance with the requirements of this Board, FIXTURE FIXTURES RANGES OVENS EXHAUST FANS OUTLETS SWITCHES FLUORESCENT VAPOR DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS SYSTEMS NO. OF FEET SERVICE DISCONNECT S E R V I NO OF CC COND OTHER APPARATUS: C A W, G. NO OF HI LEG A W. G, i NO' OF NEUTRALS A, W, G pER ~' OF CC COND, OF HI-LEG OF NEUTRAL 1 2 1 2 Motors: 1 fra~, -~2 GFCI, 2 smoke detectors--- Charl~e Mall Elec. 760 Long Creek Dr o Southold, N.Y. 11971 lic, 657-E This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERT F!CATE GENERAL MANAGER ~11 /< may be identified by their credentials. l ANY MANNER. iooi~:i THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 1003B THI~ CERTIFIES THAT in the following location; ~ Basement ~ Ist FI. ~ 2nd FL Section Bilk ~t ~s examined on ~]~ ~ ~ ]~ and found to be in co.tpllance with the requirements ~f this Board, FIXTURE I I FIXTURES RANGES C~KING DECKS OVENS DISH WASHERS ~ EXHAUST FAN~ 17 29 19 17 i 10.2 [ 1 ].2 G~ ~ric ~x COJ~Y FOR BU~ILDING DEPARTMENT. TH S COPY OF CERT, r'FICAT~E, , Mgs%~ NOT, ,~ BE A~TERED IN, ANY MANNER. FIELD INSPECTION FOUNDATION (1st} COMM ~TS FOUNDATION (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY ~ODE FINAL ADDITIONAL COMMENTS: Memorandum from.. · BUILDING INSPECTORS OFFICE ToWN OFSOUTHOLD TOWN HALL, BOX 728, SOUTHOLD, N.Y. 11971 765-1802 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.Y. NOTICE OF DISAPPROVAL To .//-~T,~....~.. ................ ..... Zo./. ..... ./e ..... ~. ..... : ...... . .~t~..~c~.,.. ~ ...... ~4Zz~ PLEASE TAKE NOTICE that your application dated ...~~...~f ....... 19 .~ .~ ..................... County Tax Map No. 1000 Section ... ~ ..... Block . .~ ........ Lot . .~ ~ ..... Subdivision ..... ~ ......... Filed Map No. Lot No. ............. is returned herewith and disapproved on the following grounds..~..~//'/~.....f.~.. ~ .~.q.6.~. ~f..~/4 ~ ................ · . .: .-7. ........ /.~.. . .~:.~,.~.~ ~.....~.~z..~ .~.... %,~.~...Z..~..~.9. :....?.~..a... ~ ~.o...~., / Building Inspector RV 1/8{) 765-1802 BUILDING DEPT. INSPECTION FOUNDATION 1ST i~"~'~ ROUGH PLBG. FOUNDATION 2ND [ ] iNSULATION [~FRAMING [ ] FINAL REMARKS: DATE ,-~tJr-~,~,~//~,~ J/ ,INSPECTOR 7GS.'~802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ]INSULATION FRAMING FINAL ~) ~/~ ~_ ? : 23.:, ~ .~ _~ : <~ , .J P.O. BOX 728 S0UTHOLD, NY 11971 FORM NO. ~0 TOWN OF sOUTHOLD BUILDING DEPARTS~T (516) 765-1802 TOWN HALL MAIN ROAD SOUTHOLD, NY ': ~' -APPLICAT£ON FOR DEVELOPMENT PERMIT Instructions: The application to the Building Inspector includes (each in duplicate) 1. Form No. l0 filled out in ink or typewritten, 2. Sur- vey of premises with elevations above mean sea level, 3. Drawings of pro- posed work. The application must give complete information to show that the proposed can comply to the Local Law No. 1-1980, Chapter 46 of the Code of the Town of Southold known as "Flood Damage Prevention Law" of the Town of Southold. The applicant must submit approvals that any~other agency requires. General Standards as required in Section 46-17 of the law to minimize flood ~amage: A. Anchoring of structures, including tanks and mobile homes B. Use of construction material and methods C. Design and location of utilities D. Subdivision proposal with drainage, public utilities design and base flood elevations .Specific Standards as required in Section 46-18r A. Residential construction B. Non-residential construction C. Mobile homes The applicant must submit plans and specifications as well as any other information requested by the Building Inspector to substantiate the facts that the structure has or will have the lowest floor, including basement/ cellar, elevated above the base flood elevation or; if permitted by the Federal Regulation, that: 1. such structure is flood proofed in such manner that below the base flood level the structure is water tight with walls substantially and impermeable to the passage of water, 2. that structural components are capable to resisting hydrostatic and hydrodynamic loads and effects of buoyancy, 3. applicant must submit certification by a registered professional engineer or architect that the standards set forth in Section 46-18B (1) (2) (3) of the Southold Code are satisfied. Coastal High Hazzard area (V Zone) 46-19. Applicant shall submit plans, specifications including-the required certifications and such other in- formation as the Building Inspector may require in that ~he provisions of 46-19 are complied with. Mobile homes are prohibited. The lowest portion of the structural members of the lowest floor cannot be lower than the base flood elevation with all space below open except breakaway walls. Sand dunes. If sand dunes exist on the premises and the applicant pro- poses to alter same, plans and specification must be shown in detailed nature of any alteration submitted. Buildin~ Permit. A Buildin~ P~rmit is.also required for any structure. both a ~evelopment and a Bumldmng Permmt must be issued before any work can start in a special flood hazzard zone. ~ written=disapproval or a permit must be issued within ten (10) working days. During construction, the inspector shall be notified in time so he may make the required inspections. Upon completion, the required certification fo the final elevations and work must be submitted before the approval to use or occupy can be approved. (Fill out the form on the back of this ~sheet) 4?80 Application Received Disapproval Issued 19 Permit FORM NO. 10 APPLICATION FOR DEVELOPMENT PERMIT In the Town of Southold Type of Development Proposed: Addition and/or Alteration[] Other (specify) ... Aug~.t 30, !98~9___ New Structure (including storage tanks~ Flood. Proof Below Base Flood Elevation[~ 2. Elevation Data in relation to above mean sea level of: (a) Lowest floor elevation, including basement 13 feet inches (b) In a V Zone, ~ottom of lowest structural me~be'~ fee-~-' inches 4. 0~er of P~emtses Ted Dowd under contract from Ralph Wengler ~. Location of P~ope~rty: .405 Smith Drive Sou%~, Southold, NY' 11971 Co~ty Tax Map No.~ District, 1000~ Section Subdivision Goose Neck Permission to be granted: Lx-~.~0wner as above~New Owner }--~Under Contraot~--~ Lesseel /C°ntract°r c/o David J. ~Dowd Dinah Rock Road, Shelter Is, NY 7. Approval from other(s) 076 Block ,, 2 Lot(s) 25 ~iled Map # 1663 Lot(s~28/129 749 lll4 before Permit is issued: 11964 DEcN/R (Dennis Cole;, Reg..,Affairs), WETLANDS (Town Board) HEALTH SERVICE ZBA BUILDING PERMIT PLANNING BOARD i, Ted ~owd _~, the applicant, am the 0wner~-~, Own'~, N~ 0Wner~], Under Oontractl--~, Lesseel---], Agentl~l, Con- tractor~, and agree to comply with all applicable sections of the Code of the Town of Southold; County, and State ~d to admit authorized in- spectors to premises authorized to perform or have performed the said work ~d to ~ake.and file this application, that all statements contain- ed in this application are true to the best of my knowledge and belief and that the work will be performed in the mannerset forth in the application filed therewith. ~'~z~::~-t ....... ~ STATE OF NEW Y0RL COUNTY OF ~d~/f/~_~S SWORN TO THIS , ~ DAY 0P Applicant s mamltng address and phone ~/ if not given abeve: 4/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Examined ................ ,19... Approved ................. 19...Permit No ............ Disapproved a/c ..................................... Application No .................. (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTION S a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws~ Ordinances or Regulations, for the construction of buildings, additions or alterations, or for re~.raovakoT~olttiom, a~herein described. The applicant agrees to comply with all applicable laws, ordinances, bu'fld, i~tffZ'o~ng md reg"uta, tions, and to admit authorized inspectors on premises and in building for necessary i~ct~ (~q,~g~~cant, or~ name, if a corporation) ,,.%Ol 1"3'~ '' 5 b (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises . .~. P.b.~.r? .~...J7.~.'7 .~...~..'7....w. ).~./?.... ! .~.~.....~.o. ?. ~... as....~.~./.L~..e..~ ........ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........ Iq../~.~ ............... Plumber's License No ...... /~//~ ............... Electrician s License No ................... Other Trade's License No ..... .P~/.f ............. l. Location of land on which proposed work will be done .................................................. .... ...w:. . . .... . . 7 .............................. . . . : ........... House Number Street Hamlet County Tax Map No. 1000 Section .... .C)..~..~. ........ Block ..... [ ............. Lot... ,,~'. ............. Subdivision ........... ~.J..~. ..................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..................................................................... b. Intended use and occupancy ....... ,, .I v ................................ 3. Nature of work (check which applicable): New Building .....~. .... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............ ?.. (Description) 4. Estimated Cost ..... ?. ~.¢?.yo..0..~ ..................... Fee ....................................... (to be paid on filing this application) 5. It' dwelling, number of dwelling units ..... ] ........ Number of dwelling units on each floor ............. ... If garage, number of cars ....... I .............................................................. ~... 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 ................. Rear ............... i. Depth ...................... Height ...................... Number of Stories ................... :... 8: Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ..................................................... ... 9. Size of lot: Front ...................... Rear ...................... Depth ...................... 10. [)ate of Purchase ........... . .................. Name of Former Owner .......................... .... 11. Zone or use district in which premises are situated .................................................. '... 12. Does proposed construcOon violate any zoning law, brdinance or regulation: ................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes iNo 14. Name of Owner of premises .................... Address ................... Phone No ............. :... Name of Architect ........................... Address ................... Phone No ............. i. · - Name of Contractor .......................... Address ................... Phone No ................ PLOT DIAGRAM : Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF ......... S.S i ............................. , .................... being duly sworn, deposes and says that he is the applidant (Name of individual signing contract) above named. He is the ........................................................................................ (Contractor, agent, corporate officer, etc.) of said owner or owners, mid is duly authorized to perform or have performed the said work and to make and file [his application;that all statements contained in this application are true to the best of his knowledge and belief; and that ithe work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ........................ day of ...................... 19 ... Notary Public, ................................. County (Signature of applicgnt) FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Exanlined...~. ~:~r..\.~...., 19 .~'.~ Approved ....~%..~.'~...~..'7}..., 19~.~. Permit No. Disapproved a/c ..................................... Received .......... ,19... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date August 3.0, 19 83 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy ,hall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for !.e, moval or demolition, as herein described. I'he applicant agrees to comply with all applicable laws, ordinances, builCin'"'g,.c-~using eode, and regulations, and to Mmit authorized inspectors on premises and in building for necessary ins!;~ctioh.~.~./~~ '~. - ..... ..... Dinah Rock Rd, Shelter Is, .NY 1196 (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Owner Xame or owner ct' premises ,. .................. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of co~orate officer) Builder's License No...~.¢.(~ ................ Plumber's License No ......................... Electrc an s L~cense No ....................... Otl er Trade s License No ...................... Location of land on which proposed work will be done...4.9.5..8.m..i.t.h..D.r..i.v.e.. S. 9.u.~.h.:' .S.o.u.'5..h.o.l:d.:' .N.Y. ..... ltouse Number Street Hamlet County Tax Map No. 1000 Section ..... 0.7.6 .......... Block 2 Lot 25 Subdivision Goose Neck Filed Map No. 1663 Lot 128/129 (Nmne) State ex,sting use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .... v,-n ...... -~ S±~gle EamSly Home b. Intended use and occupancy,, . ..................... ' 3. Nature of work (check which applicable): New Building .. X Addition Alteration Repair .............. Removal ............ Demolition .............. Other Work ............... -t~ (Description) 4. Estimated Cost.. $.3,5.,.Q .09 .......................... Fee . ./..B. !: ..~.. ........................... (to be paid on filing this application) '5 Ifdw b fd fling N mb fd Iii it h fl · elling, num ere we units ............... u ere we ngun son eac eot ................ If garage number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ...... N/,A ........... 7. Dimensions of existing structures, if any: Front .... ,N,/.A. ....... Rear .............. Depth ............... Height . . .N./.A. ......... Number of Stories ........................................................ Dimensions of sa ne stncture with alterations or additions' Front N/A Rear .... Depth ...................... Height ...................... Number of Stories ........ 8. Dimensions of entire new construction: Front ......... , ..... Rear ............... Depth . Height ............... Number of Stories .......................................... 9. Sizeoflot: Front .... 1,00 ............... Rear....1.0.0. ............... De~th .... .1.5.0 .............. 10. Date of Purchase .Cg.n.~.r..a.c.t:..A..ug.u.s.~.3, 1983 RaZph Wen let .......... Name of Former Owner ............. 9 .............. 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: No 13. Will lot be regraded .,~.~.i ....................... Will exce~ fill b_e removed from premises: x Yes No 14. Name of Owner of premises Ted Dowd ---- ~ee tieverse .................... ^aaress ................... Phone No..7,4.9 , 1114 Name of Architect .......................... Address ................... Phone No Nmne of Contractor ' Address Phone No PLOT DIAGRAM Locate clearly and distinctly fall buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, d-/'q S S COUNTY OF. ff, ~,F'~. ... ' ........... /"~'../.~,.../~..'~.. .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) ~bove named. lie is the ............................................................................ (Contractor, agent, corporate officer, etc,) :>t· said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will'be performed in the manner set forth in the application filed therewith. Sworn to before me this Notary Public ...../.3j ~4qj .,~Z .~'..~. f4 County x'x/ ' " '" Comm!~on t "t R-O'J~R]~K VAN TUYL, LICENSED LAND SUR¥'~YORS GREENPORT NEW YORK SUFFOLK CO. HEALTH DEPT. APPROVAL H S NO. :9'};O ;5i STATEMENT OF INTENT THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE SUFFOLK CO DEPT OF HEALTH SERVICES APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH SER VICES FOR APPROVAL OF CONSTRUCTION ONLY DATE H S REF NO APPROVED SUFFOLK CO TAX MAP DESIGNATION: DIST. SECT. BLOCK PCL OWNERS ADDRESS %;'~C'~ ~'' DEED. L. P, TEST HOLE 1 STAMP SEAL 6 . SSO.O ~ 5,39 OD ~ ,'-MAIN Egk',CV,~E'v~ ~D, LICENSED LAND SUR~fEYORS G~EN~RT NEW YORK STATEMENT OF THE WATER SUPPLY AND '- SYST EMS~IT~-~S~ :.oN~.p.M TO _THE ST~' SUFFOLK COUNTY ~ SERVICES -- FOR CONSTRUCTION ONLY DATE: H. S. REF. NO..~ APPROVED: SUFFOLK CO. TAX , DIST. SECT, : OWNERS ADDRESS: (T~L.. 4W'?'- 9W DEED: L,