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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765.6145
Telephone (631) 765-1800
southoldtown.northfork. net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
. -,
TO:
Southold Town Building Department
Michelle 1. Martocchia, Southold Town Clerk's Office OCT 3 0 7
FROM:
DATED:
October 29, 2007
I
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RE:
Cesspool Construction Application
Transmitted herewith is a copy of application No. 3759 for a Cesspool/Septic Tank Construction
Permit submitted by:
Cynthia E. Youn!!
Please review the application and location map and advise ifthis office may issue the permit.
Please complete the fonn below and return it to mc. 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
~
DISAPPROVE
Comments:
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Signature (~ ---'
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Dated ( I
EUZABETH A. NEVILLE . ~
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 63095 Main Ros'
.- P.O. Box 1179 .
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
sou tholdtown.northfork. net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTH OLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 /' or Non-Residential @ $25 ~
Application No3 15'
Permit No.
ApplicantName c.'/t-Ji'H \V\ E. YOlJNC-
Applicant Mailing Address PO \~C;X 383 -A"..U~~crr IVy IIQ30
Septic Tank~or Cesspool ---
Brief Description of Proposed Construction or Alteration t-JE:L0 c.O/..JSW--Uc..\t Or-...) - li()uSf,
Location of Proposed Construction! Alteration:
Owner of Property: ~~~1<\\\C\ E. 'j0\J1'!:r
Owner Mailing Address: PO li=>cx ~8 S AIAU~614.tv2:€T\ t--:Jy II q '30
Owner Property Address: 55D S~\ \\'>0 \)P-\\J~ S00Tt'1tlLD
\\<{ I (
Received by:
Name and phone number of contact person ~'1t-JTHIl'\ ,/0 UI-J&- LW') 2'=>1- 3~IO
Tax Map No: Section "1 q Block 0 3 Lot?- g
Cross Street !JO'I2\l-j ~AYIlI"'L.J
NOTE: LOCATION MAP MUST BE SVBl\fiTTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
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Date
SUFFOLK COUNTY DEPARTMENT OF HEAL TU SERVICES
OFFICE OF WASTEWATER MANAGEMENT
360 Y APHANK AVENUE, SUITE 2C, Y APHANK, NY 11\)80
(63 I) 852-5700
FOR OFFICE USE ONL Y
Department Ref. No.
-03--010.5
APPLICATION FOR EXTENSION. RENEWAL OR TRANSFER
OF EXISTING PERMIT TO CONSTRUCT SEWAGE DISPOSAL
AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING
RF.FF.R TO RF.VF.RSF. SIDF. OF THIS FORM FOR INSTRUCTIONS
PLEASE TYPE OR PRINT LEGIBLY
EXISTING REFERENCE NUMBER
Tax MaD No.
R\o--o3
Dist.
100,")
- '" 105
Sect.
-,C!
Block
Lot
2..6"
NAME OF APPLICANT C)'f'fCt\\\"\ E: - '1(j(;,l-Y.1
(If name is different from ori inal a Heanl see inslructions for transferrin a rmit and com lete section 6 below.
Mailing Address e c \.?GY- 853 A l\'\1\6~10SI:Tf r-J'/ llC(
Phone 2.107- 3810 (~K
NAME OF AGENT (If not applicant)
Mailing Address
Phone
DATE OF ORIGINAL APPROVAL ~llb 103 (lfmofe than 6 years old, a new application will be required.)
TRANSFER OF PERMIT: I hereby transfer all rights and interest in the above referenced perq,it to the new applicant named
above;
SIGNA TURE OF ORIGINAL PERMIT HOLDER/AGENT
PRINT NAME
DATE
MAILING ADDRESS PHONE
Application is hereby made to I I extend, I I renew, I I transfer for a permit to construct in accordance with this application,
surveys and plans submined. I hereby certify that I have examined this complete application and the statements therein are true and
correct, and that all work shall be done in accordance with all applicable Town, County, State and Federal Laws. "Any false
statement made herein is unishable as a misdemeanor ursuant to S210.45 of New York State Penal Law."
Signature of Applica~ . . Date
C;i.{)V-.L-~ It2' // W n - 016
Print Name of Applicant Title
~'tl0rnll'\ c.. YCtJNt- OtUNbl'\,
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 penn its are subject to any
chan es in standards enacted after the a roval date of the ori inal ermit.
DEPARTMENT USE ONLY
Signature of Department Representative
Permit is Extended/Renewed/Transferred Until
WWM-l04 (Rev. 8/05)
I am familiar willi/he STANDARDS FOR APPROVAL
AND CONSTRUCTION OF SUBSURFACE SEWAGE
DISPOSAL SYSTEMS FOR SINGLE F AMIL Y RESIDENCES
and wID abfde by 1M condll/ons set forth therein and on the
permit to construct.
The locations of wells and cesspools
shown hereon are from Held obstlf'valions
and or from dolo obtained from others.
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I DATE.3. -16-02. HS RL,'. i'E.t..1lL. ..
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\ APPROVED~_
POR MJ\XIMUM OF
EXPrRES ThREE YEARS FROM DATE OF APPROVAL
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'~'SURVEY OF'PROPER1"D-
AT BA YVIEW
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N Y
7000 - 79 - 03 - 28
SCALE: 7" = 40'
MA Y 20, 2003
July 17, 2003 fB.O.H.;
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CERTIFIED Th,
CYNTHIA E. YOUNG
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.S. LlC. NO. 49618
AREA = 23,773 sq, ft.
ANY AL TERA TlON OR ADDITION TO THIS SURVEY IS A VIOLA TION
OF SECTION 7209 OF THE NEW YORK STA TE EDUCA TICH LAW.
EXCE:PT AS PE;R SECTION 7209 - SUBDIVISION 2. ALL CERTIFICA TIONS
HEREON ARE VALID FOR THIS flAP AND COPES THEREOF ON/... Y IF
SAID MAP OR COPES BEAR THE &/PRESSED SEAL OF THE SURVEYOR
WHOSE SIGNA TURE APPEARS HElICON,
ADDITION ALL Y TO COIIPL Y WITH $AI) LAW TERM' AL TERED BY .
MUST BE USED BY ANY AND ALL SURVEYORS UTILIZING A copy
OF ANOTHER SURVEYOR'S MAP, TERMS SUCH' INSPECTED' AND
. BROuGHT' TO - DATE' ARE NOT IN COMPLIANCE WITH THE LAW.
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NOTE' LOT NUMBERS ARE REFERENCED bTO
. SUBDIVISION MAP OF BA YVIEW WOODS ESTA TES'
FILED IN THE SUFFOLK COUNTY CLERK'S OFFICE
ON SEPT. 9, 1970 AS MAP NO. 5520
C'.I?.s /sc".;
ELEVA T/ONS ARE REFERENCED
TO AN ASSIAiED DA TIM.
STREET
N. Y. 11971
03 - 164