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Home My WebLink About17541-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No 218104 Date JUNE 12, 1989 THIS CERTIFIES that the building ONE FAMILY DWELLING. Location of Property 3300 HAYWATERS ROAD CUTCHOGUE House No. Street Hamlet County Tax Map No. 1000 Section 111 Block 11 Lot 12 MAP OF SECTION D Subdivision NA5. PT. CLUB PROP Filed Map No. 806 Lot No. 413 conforms substantially to the Application for Buildinq Permit heretofore filed in this office dated OCT. l4, 1988 pursuant to which Building Permit No. 175412 dated OCT. 18, 1988 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 ONE FAMILY DWELLING WITH DECKS ANL1 GARAGE UNDER. The certificate is issued to JOHN R. DEMPSEY, INC. (owner, xxxxxxxxxxxxxxxx) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 87-SO-160 5/11/89 UNDERWRITERS CERTIFICATE NO. N066432 APRIL 12, 1989 PLUMBERS CERTIFICATION DATED GALE KASKE MAY 3, 1989 Building Inspector Rev. 1/81 gosaa xo. s TOWN OF SOUTHALD BUILDING DEPARTMENT MOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON TtiE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N ~ G 17 5 41 Z Date ...~.s.,~~-~:Q::~r.......... ~. g .............. 19.7 ~? Permission is hereby granted to: ct premises located at ......................T.'.t~.4N.::44!4~r1-°.....Fr9............~r:~!~C.k~:,,~+................ .. ..... ~........ ,..~ .~..... i~....... .. ~(G,..,. ....................................................~............. County Tax Map No. 1000 Section ........~.I./......... ,,//Block .....~~ ............. Lot No.....~................... pursuant to application dated ...~.~.~'~?~......L.7 ....................... 19.d.~.., and approved by the building Inspector. Fee $..~`~..:..:/ ...8..' ding Inspector Rev. 6/30/80 TEL. 765-1802 ~~FFO(.If~~oG TOWN OF SOUTHOLD y~c OFFICE OF BUILDING INSPECTOR ~ z P.O. BOX 728 ,ten ~ TOWN HALL `"QL-O~ ~ ~~0~ SOUTHOLD, N.Y. 11971 C E R T I F I C A T I O N Date Mao 3. 1989 Building Permit No. 1']541Z Owner John Dempsey' (please print) Haywaters Rd:., Ct3tchogue, N. Y. Plumber Gale Kaske (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1g lead. ~~ ~.~ ~ - ~_ ,1( plumbe 's signature) / ~/ Gale gaske Sworn to before me this ~ ~O~ay of _%/ 19 ~ ~ N ary Public Notary Public, -Su~~~~,~~ County ROSE H. DON~NELLY Notary Public, State of New York No. 524624196 Suffolk Goumgl iTtirgt ~xpirfS ~ w,..._ 3 3 / 9 9 ' FORM NO.6 " TOWN OF SOUTHOLD Building Department , , °"'" Town Hall Southold, N.Y. 11971 ` 765 - 1802. ~~ - APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. B C. This application must be filled in typewriter OR ink, and submitted ~~..~~ to the Building Inspec- torwith 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, acertificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of psbperty showing all property lines, streets, buildings and. unusual natural or topographic features. 2. Sworn statement of owner or previous owner 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. i Fees: ,Additions $25.00 1. Certificate of occupancy New Dwelling,$25.,0.0, .Accessory;-,$10.00 Business $50.00 2. Certificate of occupancy oripre-existing dwelling $ 50.00 3. Copy of certificate of occupancy $ 5.00, over 5 years $10.00 4. Vacant Land C.O. $'20.00 Date. ••••• 5.Updated C.O. $'50.00 ••••••••'•"'"""' Ne~wConstruction„,,,,•OldorPre-existing6uilding .....:...... Vacant Land ............. Location of Property Haywatei`s', Rd. ~ , Cuteho~,ue ~, N. • Y.• • • • , • , , , , , , . , , " ; .... . ' Street •Hamlet Nouse No. Owner or Owners of Property ..SCl~A.pEtApsey.••••••••••••••••••••••••••""""' "_'•" County Tax Map No; 1000 Section lza, ......... .Block ..ll.. Lot ..pc~..12 i~ Subdivision .~81~ .0~. S9Ct~-.o~l.p, • • • • • • ..Filed Map No. $06. • - .Lot No.yy~. .. •.. • Nassau Ft. Club Propex•ties, Inc. Permit No..1~.541Z.. Date of Permit 10;!18/88.Applicant .In1•and. H.am~s~• •ZiaE•.• • • Nealth Dept. Approval5h,1/89 . . . . . .. . ........Labor Dept. Approval ....... • • ~ Underwriters Approval ~R~~!+,7j,~ .. • • • • .........Planning Board Approval ............. • : • • • Request for Temporary Certificate .....................Final Certificate ................... . Fee Submitted $ 25,0.4 ................. .. Construction on above described building and eets all ap licable codes regulations. , APPlicant ... .~.-. ... . ; . .. . Robert E._Hi1tz - lazt H ~e , Zne-p"~ pev. 10.7048 ~ .. eo zi~i~y _ s e K' -1E1~ II:SPEC.IU;J ~ ~UATE ~ COhiMENT3 O 1 ~ . ^'~ 1 . \/ . _-__ . H H FOUNDATION (1st) ~ ~ a ,. _ Y c6~ ~~ m~ FOUNDATIOtJ (2nd) 2 . z o V ,~ ROUGH FRAME & a z z ~ /.~ -PLUMBING .- r 3. ~ I1ISULATIOPI PER N. Y. ~ • • y c STATE ENERGY CODE t~ x fc ~P ~'~ ., ~ 4 . y FIidAL tiw~. ` ~ 4 fio 81 - z x ADDITIOtIAL COMMENTS: ~'~, s Arm=. ° _ a , ~ o F!g„~9'~.~ ~ o ~~ ate. 6 ~ ~ cn x ^ o H ~ 9 ,j ~ "` H O „i Z C / I RJ 01 • A .~ r ~ ~ G c d t m ro 6 y a 7 ~ 765-1802 BUILDING DEPT. INSPECTION ~p~Y ~~ [ ]FOUNDATION 1ST ( ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ FINAL REMARKS: ., D ,~ DATE 7/~ 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION iST [ ) ROUGH PLBG. [~ FOUNDATION 2ND [ NSULATION [ ]FRAMING [ )FINAL DATE ~ ~ 1 REMARKS: ~ ~~~-i~J ~ /C~_ ,~" 765-1802 BUI4DING DEPT. INSPECTION [)FOUNDATION i5T [ ROUGH PLBG. DATE 7i '~/~" ~ INFiPE~C'TOI~ [ ] FOUN TION 2ND [)INSULATION [ MIND [ }FINAL ~~s `~/ ~ 765-1802 BUILDING DEPT. INSPECTION DATE t ~ ~~ I [ ]FOUNDATION i5T [ ] ROUGH PLBG. ~/~OUNDATION 2ND [ ]INSULATION -,s`~l ~ 65-1802 ILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION DATE O INSPECTOR "~ [ ]FRAMING [ ]FINAL 17~ l ~1~ THE NEW YORK BOARD OF FIRE UNDERWRITERS 1=lae~l~. 1-f `1b#1 ~ BUREAU OF ELECTRICITY i ~ 8S JOHN STREET. NEW YORK, NEW YORK 10038 Date `~(''fi}}' '(=r~}gl$li Application No. on file E3'}~};~3Qfrj'3f ~~ [~t l]kr 4T{''-.t,{ THIS CERTIFIES THAT only the electrical equipment as deacrihed below pnd introduced 6y the applicant Homed on the above application numher in the premises of :7ti)fti$ Ali{A1;'i1{V, '3f;,'VHA`i'7:{~;i fa?1111, Y>e1!',i~; j3i/IS S;F7i(aYrTty47~;, ~.X. in lhefollowinq location; 0 Basement ~ /st FI• ^ 2nd F'l. 3ertion B(oek Lot uns examined an (g, ~,fl i~'19 1,`3, i}};d rl andfound[o be in wmplianre with the rw/uiremeats q(this Board. FIXTURES RANGES COOKING DECK$ OVENS DI'aH WASHERS EXHAUST FANS FIXTURE ECEPTAC4E5 $WISCHE$ OUTLET$ INCANDFSCEN7 FIVORESCENT OTNER AMT K W. AMi K.W AMT. KW. Ami. K.W AMT H P DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI.OUTLET DIMMERS AMT K. W. Oll H. P. GA$ H. P AMT. NO. A W. G. AMi. AMP AMi AMPS TRANS. AM}, q p SYSTEMS NO.OF FEET AMT WAiiS H' f ~ SERVICE DISCONNECT NO.OF 5 E R V A C E AMI AMP, TYPE METER EQUIP. 1 R, ]W ~ ~. 3W 3,e 3W 3,e 4W NO OF CC COND. PER 9 A W. G. OF CC COND. NO Of HbLEG A W. G OF HbLEG NO. OF NEUTRALS A ~`' ~'~ OF NEUTRAL } 3 fxt' till 'l. 7, ~ t. x, ~ 1. OTNFR APPARATUS: U~,.,C,.S.'~> :,FP1KT,d i5:h"I'FIC.°PTIiKZ ~ 9 SY~P: Tf( 3,A.IlAi[4ll`SfS l.i:d;~- it;~l; ., {fi SU ~i Ji', 1~!A''~~%~%C.C// ~~ ~~ ~~~~ ,ii?IF'{'91051I1, dS~'r fitt'F: l 6~NERAI MA ER l ''~ Per This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by h u credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER 3. Nature of work (check which applicable): New Building ~X.. ,~..... Addition , .. , ...... Alteration ......... . Repair .............. Removal .............. Demolition ........ , ..... Other Work .......... , ... . (Description) 4. Estimated Cost.6O,,000, 00,,,,,,,,,,,,,,,,,,,,,,,,,,Fee ./~~~.: ................................ (to be paid on filing this application) 5. If dwelling, number of dwelling units ..... 6 ........ 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. Dimensio I tiiat "~ " ' Mures, iflany: Front .............::Rear :............. Depth .............. . ,• Ifeight i "' ~~s~`v IVuinberP~Stories .............. .................................. Dimensio '' same structure with alterations or additions: Front ................. Rear ................. . Depth .. { ..... .~. ` . ~~>~... Height ...................... Number of Stories ..................... . 8. Dimensio entire new construcfi4n:,Front ..'1Q..1 ........ Rear ....~>.Q.... , ....Depth JQ ........... . Height .... .:,~Y~t ~'"x;T`Ninber of Stories ......... ......................................... . 9. Size of to Fr ..~~.N ~~,.:'::.,,........ Rear ..... 90 .............. Depth ....260.............. . 10. Date of Purchase .............................Name of Former Owner ............................ . ] 1. Zone or use district in which premises are situated .......................................... . ......... . 12. Does proposed construction violate any zoning law, ordinance or regulation: .rip ............................ . 13. Will lot be regraded ............................Will excess fill be removed from premises: Yes No 14. Name of Owner of premises Johxt. AempSey...... Address .Cut:Chogtze_rN. Y.... Phone No.:7.3t}_G0.5g .... . Name of Architect ...................... . ....Address ...................Phone No............... . Name of ContractorIrilaZtd. Iiomes.,..InC........ AddressBox. 1.1'~~P'fattitu.el@hone No. 2.9II-9696 I5. Is this property located within 300 feet of a tidal wetland? *Yes ..... No ..... *If yes, Southold Town Trustees Permit may be re_gwired. 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. 0 (~ ~. .o a ~` ~ v, "' .o h ~~ Ge r1 ~ ~. ~~ ~ 0 STATE OF NEW YORK COUNTY OF .. S.u.>il~Q~ , , , , , . S.S ....... . ..... ~.o.'b@]I't..F,. , Hll.tZ................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. Ile is the.....COritxBCtA.ri .......................................... ............................. (Contractor, agent, corporate officer, etc.) of 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 .............../.~ ......day of ... d///~............., 19 ~~ Notary Public, ... ~~e'`' ~ r" ~. `.~.-...... County J ---~~ NEIEN K OE V4E NOTARY PUBttG $qAe of hew ............ .. ............. PP :... . TeNm~E4KpiresMaetch30.I9~ Robert E. Hiltz (Signat ofa hcant) FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 y,, TEL.: 765.1802 Gxantined . ° St! .~a-t., ,(.$ ., 19~~. ; - Approved . QS~.~, 1.~ ., 19$~. Permit No........... . Disapproved a/c .. , .... .... .. ........... . ........................... .QNf~"a:. ... .... (Building Inspector) BOARD OF HEALTH Y...... 3 SETS OAF PLANS .'~ . SURVEY T. CHECK ~ • 1•~ ~3t1 SEPTIC FORM ..'~.......... NOTIFY CALL ......... .... MAIL T 0 : ~~Tl~pir+R ~S>'i-~o/ ~rx 117 APPLICATION FOR BUILDING PERMIT Date Optgbex'..12......, 19Ei$ . INSTRUCTIONS a. This application must be cottiple'tely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to sale. 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- ca@iat. 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 Me~DE 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 o#' buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. IN?,AND, HOMES,,, ,INC., , , , . , ...... .. . (Signature of applicant, or name, if a corporation) ....Box .11~.,. ,Mattituclc, .N...Y.. 11.92• • • • . (Mailing address of applicant) State whether applicant is„owner, lessee, agent, architect, engineer, general contractor, electrician, plumUer or builder. ..................Genex'a~..GolltxactAx........................,............................... Name of owner of premises . dAk~l',,.$...~9TPPS.~3.' ~ ..~1Q. ..................... ......................... . I~ (as on the tax roll or latest deed) If applicant is a corporation, signatuFe of duly authorized officer. ......Robert .E.. Hilt.,. . Preazdent....... (Name and title of corpo{ate officer) ALL CONTRACTOR'S MUST 'BE SUFFOLK COUNTY LICENSED Builder's License No . ...... ................ . Plwnber's License No. . 2q.51~...... • .......... Electrician's License No. ~73;~ ................ . Other Trade's License No. ...~ .................. 1. Location of land on which proppsed work will be done. . , var4e.~3~..Ha~watex..Rd...4eeLo ............ . ~?+.., .'at. Nassau.Point........~-.~J+-,-=-,.. ........................ I.Iouse Number ~ Street Hamlet . County Tax Map No. 1000 Section ,~ a'1T, , , ..... • • C1iz~l6l'~O'~1 ~' Ti1C ;' ' ' ' ' • • • Lot .. 12 ...... , • ..... . Subdivision MAP . P~ .S80t.•..'~. ~&ssau Point . • • ,Filed Map No. 806 • . , , , . , , , , Lot ...~'i3... • • . (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'... 1-. Family,dwellin~ ,,., ~, ,,,,,,,,,,,,,,,,,,,,,,, ~ 4ilELL f 1 ~~• e, ~~ E~E~ 1' , C 2E51 DENCE) ~ , 105 1 ;~ ~: ~' tvacrwn~r) s J ~~i-' I ' F100 L ~~ I ~~ ~` t+1~6 S'33OyE. ~_ ~ __ ,L 122.0 ~~ ~ PROP , x ~ILi ( VACa>NT) b~ ~' '260 D 2 U `~ U ,a "T~ a j ~; ~ ~ P_ `' tD 2 : V' . ~~ 88.o n, O > ~ pl ~~, \ ', o - ~~sr•-; 413 ~^ ~ NOOSE tx ~ l ~; ~ '~ ~ 11 ~ ~ i._ / ~ 'n DQIVE _f ~{ --- ~ b a - ' ~i _---- 5.80'23 30" W. _--_- _ ~ ---- r>=sr ib1.E ao -- -- 235.0 l~~ r - 414', ~ +~ ~, S ' ~ ~ ~F~iGF. ~ ~. ~ s w. I i , react. Q ~P ~. ! I-_ ~_ ~ '~ ~ CesSPaO' w~ _ ~ neovosED _ - _ ~~~-t l~ ~= d ~._ /~ ~ f 1 -, r ~:Lilc'V`t ~Y~."is f~.J:c. ~. ~, ~ ~,. ., . ly Q 3 Q r 50 -- SUFFOLK CO. HEALTH DE-T. APPROVAL H. S. NO. FI~MILY DW~LL(NG ONLY E RS FROM'•DATE OF APPROVAL ~ATEMENT OF INTENT THE WATER SUPPLY AND SEWAf.E DISPOiAL SYSTEMS FOR THIS RESIDENCE W14L CONFORM TO•THE STANDARDS OF THE SUFFOLK CO. DEPT. OF HEALTH SERVtCEf. ISI APPLItIINT SUFFOLK COUNTY DF,PT. OF FIEALTN - SERVICES - FO'R. APiPRO,YAL OF CONSTRUCTION ONLY 9 Y y/~ ~- - ` DATEc H. S. REF. NO.: ~ ~ ~ ~~ _ / i i POOL ~ - `=4 . . SCALt Q= l~ ---- I Af2EA`23 5465. F. G~ MCNU1~3EniT G•_I~zcr~ ~l~e i.LQT 'w:~ (1EF f '< TG~MAN ;:f ~~Cr C~- - --_ _ _ _. hiA~SAU POIr., ;" ~.Ub P2C~PE{2'" c S,iNC,., F!~ED IN'*I-iG SUF~F ~~~ I,kE~elti'` uF'1=ICE F~ MAP No.806. 2.-dNTJ'z~ 2FF'Efd T~.~ MEAN 5EA -----~- --_...~..-.. __--_._ _....__ ._-. ~ .r E1EL. WC V 1 ..~G V 1 ~ W~_ 81 1~~~ ,airy R; S~+.J'''_HUL~_SAVfNvS 8,4 1.T Q ~ R~RICrK VANwT~,YL, -~. LiCEN9LD LAND StMlV[YpltE 191REENPORT NEW Y¢ItK SUFFOLK CO. TAX MAP DESIGNATION: DIET. SECT. BLOCK PCL. ICJOQ 111 . I 12 P Q 6ii X 5 rvTC+-IQGIJt_~ N.Y. 11y3~ 7ng- 6p58 rDEED: L. S{41 P.5Y8 ~F. AUMU3 1+ . ~. ;..NO'i~^A ialwa!1an K aQ'Vtln11 •r. Ilia survrry is m viMetiat N WL.BRQWN ... z::.n 7'~A4 d iryn Nae Ypk BIOM -,,;,~.amn law. LoXF1 ----- ---- '~,• m.,,,,a d they s-.nro tnao rcx baln7 rr .. la~.y auniymr a iMM esoi r ti ' "Ix"'sse, sad ahNl not 6m aoaellaeed BRO ifN to 4a r vali? tum Dopy. ~A~I r ua[ankw InlimcM7 hGr1N1 lhOt M --...~~.-_.~ 1.3 a 1~ r~ the Pxaan fpr wttxn 1M e+M! ~-m anersd, rrW mfl He baMNN1M yy rJANV V tR [orn'Mny, ¢warrnlnmflbl b'X~ mfb lar!ave inSlnlNdl hNad Iwcen rd L01~M . to ihs aeaignaae of kw NutYnp 4aaY- r,..~;.n. G:xvaniaea rm nea •amlarmiA ---_-- -- a5 ..ui~.:a^. a'italtittMlNraYhaWYaM CMR$E ~~ t UFC,~~ K ^1VTV t~ ~' ~ ~ ~''~ 1 1~+Et 1 ~ Nv r, ~F, E ~" I '- ~ j .~ .~ ,t ` ' } ~ ~ -/ tl N.7E> `%3 ~{~ E. ~lD ;;7 ~ ~~ _ __ _ ~-- _ ._ _._ _ e-I __ _ -_ _.I _.._. .._ - __ . 8--- __ - ~ E- i 172.0 -e3d.4 ~1 [ } ~,~ ~' ~ _ -- _ ~ y~ ~ ,~•~2Y~~ - __ t~RREI'_MMLLS E` I1~ ~ ~ , - ~ ~.~ DECK ~ - ~ ~ -_ _ `t ' ~ i ~~ 1 , _POOi_ ^^^111 - ~ > ~.;.,,U SEVrtc 'r~i ~ EA12TH ~ ~ ...~ ("~ 'C -~-- D21VF ~ 't - ~_ TM ~_ .._.:. -__--~_-._ _.__. Jto...: ~ : .. F3E2 CI128 - - , , ~ ~ n; ~- +i,i ~ t <. ^}~ ,. ..._ ~ i ~; _ -_. lI'; ~(., r.,. i. _ _ .. 4.) Ilo , ~I ! ''1 I - ~ ... ~ , , , -- ` - ' I .. ..._ ._ i . ,.. _ - . •1. f L.. y l f.~l ; *~' - . S -- SUFE(?LI' ObUivTY ~L: '1R?MINT OF HEP,LiH SERVICES _.. y'J . _ ,. ~ r ... ~ T+.;: '_'i , , . - ~ 7 i"r'"Ir.;S 0f if1~S I ~_~, „ ~,,t~,ent and/or _/ l l r C~ief ! ii:~- ~ ° ~,Vasie~+ater Management 2~vl~rf rw~ e, i9C371 USC_ zo. X988 - - - - -- - + - a .. /~ ~ ..y 1 4 i~r'`~:'" r.._ _-~rl , EYED LF:C 1 ~I~r£i6 ROpERiCK VAN~L, P G. ~ ,lam ~/ .«....- i-~+.~. LICENSED LAND StNFVfS GREENPORT N6W Y RK SUFFOLK CO HEALTH DEPT APPROVAL H S NO. 3'7-SG IF,O I i :+ ~-_. _ _--- - -- --- ---- - 1 STATEMENT OF INTENT j THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESIDENCE WILL p CONFORM TO THE STANDARDS OF THE ~ SUFFOLK CO. DEPT. OF HEALTH SERVICES. ISI U~ APPLICANT l SUFFOLK COUNTY DEPT. OF HEALTH SERVICES - FOR APPROVAL OF CONSTRUCTION ONLY DATE: H. S. REF. NO. S?"~" ~~ APPROVED. i SUFFOLK CO TAX MAP DESIGNATION: i DIST. SECT BLOCK PCL i~;r] f I 1 ~ OWNERS ADDRESS: r` ~- ~ _~~ i . ~ i 0 DEED: L. ~1q1 P ~; ,^ ' '+ y _ -HUr+f_u5 E DK.6Q~WN ~~K~V~LRry ;.tJAM ~.Nav ~~ ~O/fGd$E a~AhiU E7 :J: t`9 CC`:iS1Al~':'#1 '~' ., I 6 hn,'. ow v . h.S .:OL Je. ~ .I.n...: e. o ..V 1. 'ASiO.'1R i1S SULrtY2u@Af ilLEDYNE AST NBI]!o ' /, r