HomeMy WebLinkAboutAnderer, Peter
11~LIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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-Southold Town Building Department
FROM:
Michelle L. Martocchia, Southold Town Clerk's Office
DATED:
July 3,2007
RE:
Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 3723 for a Cesspool/Septic Tank
Construction/Alteration Permit submitted by:
Peter Anderer
Please review the application and location map and advise ifthis office may issue the permit.
Please complete the form below and return it to me. Thank you.
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I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
v-
DISAPPROVE
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SIgnature
67~C.~7
Dated / I
Comments:
ELIZABETH A. NEVILLE ...,
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
".,Town Hall, 53095 Main Ros
P.O, Box 1179 .
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown,northfor k. net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $ I o.L or Non-Residential @ $25 _
Applicant Name fir,?' ri€ 4'\/ d ~ (}2. ? "e
Applicant Mailing ~ddress (p 0 0 &~ r.;;+
Application No~ 1~
Permit No.
Septic Tank~or CesspooL-.- ,
Brief Description ofPropo~ed Construction o,r ALteration ;J 2. tv'
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Location Of, Proposed const~on/ Alteration (
Owner of Property: -:i.k- ,Jd.A..A.'<---
Owner Mailing Address: fee> () ~ -;{
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Owner Property Address:
Name and phone number of contact person
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TaxMapNo:/lN'O SectlOn/OJ.9 Block =003 Lot /)-/8
Cross Street '7 S t-. ~ -
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURvEynH HEALJ~..nEPARTMENT APPROVAL
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Sign'ature of Applicant Date
Received bY:~adrrS' ~~
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I am fam/Her with Ihe STANDARDS FOR APPROVAL
AND CONSTRUCTION OF SUBSU/fFACE SEWAGE
Df$POSAL SYSTEMS FOR SINGLE FAM/L Y RESIDENCES
and will abide by Ihe contlllions sel forfh fherein and on Ihe
permJ/ 10 conslrucf. .
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ELE:VA TlONS ARE: REFE:RENCED
TO AN ASSUMED DA TUM.
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BRO IYN \ 100.00'
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SURROUNDING DWeLLINGS U
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ANYI AL TERATIDN OR ADDITION TO THIS SURVEY IS A iVIOLA nON
OF SECTION 7209 OF THe NEW YORK STATE EDUCATI!jN LA II.
. EXCEPT AS PEil SECTION 1~09-SUBI1IVISIDN e, ALL C(l/mFICATIONS '
HERtDN IlRf. VAI..ID FOR THIS MAP ,ANI) CDPIE'S THEREOr DNL Y IF
:'sAID /'lAP' DR COPIES BEAR THE II'fPRESSED SEAL OF T~ JiURVEYDR
\.{fIDSE ..SIGNIlTURE APPEMS HEREON.
LOT NUMBERS RCF6R TO
PARK' FfLE:D IN TfI'IE: SUi
ON DEX. 1, 1909 AS MAP
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SURVEY OF 'PROPERTY
AT '.' GREENPORT
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
/ 1000-48-03-17 & 18
SCALE:' 1 "=20' .
SEPT. 3, 2002
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( COUNTY CLE:RK'S OFFICE:
36.9, '
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT FOR ApPROVAL OF CONSTRUCTION FOR A
SINGLE FAMILY RESIDENCE ONLY
!?IO-tF3-0/ltf
DATEU-IO-C?'3 H.S. REF, No,
ApPROVED
FOR MAXIMUM OF
EXPIRES THREE YEARS FROM DATE OF APPROVAL
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FAX'(63P 765-1797
(631) .
p, 0, BD
1230 TRAVE;,LER STREET
$DUTHOLD>'i No y;. 11971
02-23
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S~i"FOL
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SUFFO
Department of Health Services
Office 0 f Wastewater Management
360Yaphank Ave.
Suite 2C
Yaphank, N.Y. 11980 ''~I-~5...'S700
:ERVICES
NT
Y 11901
FOR OFFICE USE ONLY
Health9fpartment Ref. No.
K ~O-03-n
APPLICATION FOR EXTENSION, RENEWAL OR TRANSFER
OF EXISTING PERMIT TO CONSTRUCT SEW AGE DISPOSAL
AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING
REFER TO REVERSE SIDE OF THIS FORM FOR Il'iSTRUCTIONS
PLEASE TYPE OR PRINT LEGIBLY
EXISTI:\G R'ER~~E~'J~~R_ D I I -
Y
Dist. Sect. Block Lot
Tax :--.1ao :--Jo. I nuD 't'6 cD.?:, I 'I <<1" /2
NAME OF APPLICANT Pt:: / f {2 4 tJ d e iZf L -
(If name is different from oril.!inal annlicant, see instructions for transferrin'" a ncrmit and comnlcte section 6 below.,! C t: '-L~ ,,~/- 7 g G, . - ')." C;. '2--
Mailing Address GrDO 1'3 t'6 LU A/ ST Phone G, ;);. L..j))-)1{:')
NAME OF AGENT (If not applicant)
Mailing Address Phone
DATE OF ORlGlI'AL APPROVAL 1/- I 1.:>. 03 (If more than 6 years old, a new application will be required.)
TRANSFER OF PERMIT: I hereby transfer all rights and interest in the above referenced permit to the new applicant named
abO\"e;
SIGNATURE OF ORIGINAL PERMIT HOLDER/AGENT --'.
PRINT ?\A:vtE -....----.----" DATE ...
--.--.'..". .--
MAILING ADDRESS PHONE
Application is hereby made to' k'extend.'J I renew, [ 1 transfer for a permit to construct in accordance with this application,
surveys and plans submitted. I hereby certify that I have examined this complete application and the statements therein are true and
com:'ct, and that all work shall be done in accordance \',rith all applicable Town, County, State and Federal Laws. "Any false
statement made herein is nunishable as a misdemeanor nursuant to 8210.45 of New York State Penal Law."
. SignaVf APPliC~? Date
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Prill! I'\'ame of Applicant /lvd t r2 t'v2 Title
Pf)'iV2 C) vJ !./ 'i ,,"--
If you are making Substantial revisions or modifications to a project that has already received a permit to construct from the
Department, or it the permit is more than six (6) years old, a new application will be required. Renewed pennits are subject to any
chan!2es in standards enacted after the annroval date of the original permit.
DEPARTMENT USE ONLY
Permit is ExtendedlRenewedlTransferred Until \ \ - i 0 -Ocr ..4mber of Bedrooms Approved 4
(~-2 ( --.-
Signature of Department Representative /7"'C7\. .P1 ?tA""-Ite \ 1_ \'3. 0 0
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WWM.104 (Rev. 3/03)
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