HomeMy WebLinkAboutGoldner, Eileen O Estate ofELIZABETH A. NEVILLE, RMC, CMC
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
TO:
FROM:
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Southold Town Building Department
Carol Hydell, Southold Town Clerk's Office
JUL 15 2009
BLDG. DEPT.
TOWN OF SOUTHOLD
DATED: July 14, 2009
RE:
Cesspool Construction Application
Transmitted herewith is a copy of application No.
Permit submitted by:
Charles W Southard~ Jr.
3885
for a Cesspool/Septic Tank Construction
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and retum it to me. Thank you.
I have reviewed the application and location map of the project cited above and make the following
recommendations: ~
APPROVE
DISAPPROVE .
Comments:
Dated
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
~Residential ~ $10
Application No.
Applicant Name:
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
or [] Non-Residential ~ $25
Septic Tank ~or Cesspool
PermitNo. "~ ~
Applicant Mailing Address: '-7 1.k3 ~"~ _t~(4 ~
11967
Brief description of Propsed Construction or Alteration: ~ ~
Location of Proposed Constmct~Alteration:
O~er of Prope~: ~ O~ ~
O~er Mailing Address:
Property Address:
Name and Telephone No. of Contact Person:
Tax Map No.: Section: 5_6
Block: 0 ~ff- Lot:
Nearest Cross Street: ~ k)00 ~ 19 OA',60 (~) ,~-13
~it~ Sig~p~ Date
Received by: ~ [
05/26/2009 i2:i6 6317347712 OLSEN LAW PAGE 82/02
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES J.F,.O. IL.OX. EI_¢E USE OIlLY OFFICE OF WAaT~WATER MAIlAGEMENT
360 YAPHANK AVENUE, SUITE 2C, YAPHANK, NY 11980 ]Health Department Ref. Ilo_
(63 I) 852-5700
!
APPLICATION FOR EXTENSION, RENEWAL OR TRANSFER
OF EXISTING PERMIT TO CONSTRUCT SEWAGE DISPOSAL
AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING
Z ..... PLEASE TYPE OR PRINT LEGIB~L~
XISTIIIG REFERENCE NUMBER
R10-0S,4)094
Tax Map No [ "~'i's't'" I Scot' I Bl°ck1000 56 5 22 Lot
NAM§ Oi~';ii~'£I~XNt ESl'ATE'~I~ Rn~ O.'~ ......
Mailing Add.ss 26 ~ RO~, ~ <11 ~, ~ 11530 Phone
NAME OF AGE~ (if~t ~li~0 ~N-CONS~TANTS~
~ailingAddressl319~R~RO~,~N,~ 11~8 Phone
DATE OF ORIGINAL APPROVAL 47/~ Ofm~ than 6 years old, a n~ ~plicag~ will be
T~N~e'~K OF PERMIT: l ]i~i~l;y transfer MI righrs ~d i~st in thc fl~w ~fe~n~d permit ~ ~ new ~pHc~t named
~w;
SIGNATURE OF ORIGINAL PERMIT HOLDERJAOENT
PRINT NAME __ DATE __
MAILING ADDRESS PHONE
ApplicatiOn is hctuby made t~ [~l~ extend, [ J renew, [ I tranafe~ for a permit to construct in ao~ordance with this applie, ation,
surveys and plans subnliticd. I hereby ~rtify that I have examined this complete application arid thc Statements therein are troc slid
correct, nnd that all work ~sl~all bo dona in aneordancc with all applic, ablo Town, County, amto n~ Fodoral Laws. "Any false
~tntemcat m ,ad,e he. in ia ~uni~hable as a mlsd=mannor pursuant to S210.45 of New York State Penal Law."
S;~n~iur~ of Applica.~__ Date
. . ~ -,.,-, Fgr/:~I-IARY 13, 20(0'
Print Name of Applicant ~ Title
ROBERT E. HERRMANN
If you nfo making Subs;~i~ii~ revisions or modifications to a project that has airead, reeeivod a permil to oonsln~ot l~m tbe
Department, o~ it thc permit is mom than six (6) years old, a new application will be required. Renewed permits are subject to any
~han~s in standards em~-t ed ai~r fl~e..al~roval date.~f the uri~inal~e~i.t.
DEPARTMENT USE ONLY_
WWM-104 (Rev. 8/05)
! ' ':""; i: Page 1 of 2
NOTES
Joseph A. lngegno
Land Surveyor
82'5!'20,, £
TEST HOLE DATA
~URVEY OF
LOT 20
MAP OF SUBDIVI.~ION
WILLOW POINT
FILE NO. 4652 FILED JUNE 16. 1966
AR3HAMOMA~UE
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK~
S.C. TAX No. 1000-56-05-22
SCALE 1 "=50'
MARCH 50, 2003
FEBRLJAR L'3, 20)5 ADDEE PLOF ~N
~pQ~E.~ ~ONC. RE~AIB[B~ ~ALL DETAIL
?~'%'E;:t-'° PROPOSED SEPTIC SYSTEM DETAIL
/- ~',~"y~'~ .... Z_._:'~ ~'_
AP~ ST[APN1KC J~-A~ PIPE ~~ El L~CHING [{T l~r~
SEPTIC TANK (1)
LEACHING POOL~_~}