HomeMy WebLinkAboutRoss, David & LibbyELIZABETH A. NEVILLE, MMC
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS OF 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.nor th fork.net
TO:
FROM:
DATED:
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Southold Town Building Department
Carol Hydell, Southold Town Clerk's Office
September 20, 2011
RE:
Cesspool Construction Application
Transmitted herewith is a copy of application No. 4043 for a Cesspool/Septic Tank Construction
Permit submitted by:
Samuels & Steelma~ for David & Libby Ross
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and return it to me. Thank you.
I have reviewed the application anC~ocation map
recommendations: / of the project cited above and make the following
APPROVE
DISAPPROVE
Comments: Final approval required from the Suffolk County Health Department,
Signature ) ~
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFO~TION 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
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 / or Non-Residential ~ $25 __
Application No. q O q 5
Permit No.
Applicant Mailing Address ~ ~3~' /~,4t/'/t/ /~-/' ~FC[~t~(-J~'~.- /f/~
Septic Tank g/ or Cesspool
Brief Description of Proposed Construction or Alteration
5~,Sr.c'"M, oc'ab~?~cr,, ot/ of /vO-Tx/
Location of Proposed Construction/Alteration:
OwnerofProperty: q~)j~v/[~) ~ L~7~t/
OwnerMailingAddress: ,-~' ,Db{J30[.ff ~ b,/~(~, C'"/"
O ~TLO
Owner Property Address: {70 gOt~--ir~( /~-(J~. (~ ~{0~
Nme ~d phone nmber of contact p~rson T~ ~ O~ ~ ~ ~- ~q~
t~ Map No: Section }~3 BBck 0 ~ ~t ~ ~, /
Cross S~eet /( ~ ~ / ~
Si~at~e ~f ~pplicant ~ Dat~
Received by: ~,
SEPTIC PROFILE
Si i E DATA
SCTM #
PROPERTY:
ADDRESS
OWNER:
1000-123-08-24.1
170 PARK AVENUE EXTENSION
MATrlTUCK, NY
DAVID & LIBBY ROSS
68 DUBOIS ST., DARIEN, CT 06820
28,043 SF = 0.644 AC
4,487 SF WETLANDS
R.4O
PECONIC SURVEYORS, PC
PO BOX 909
SOUTHOLO, NY 11971
LICENSE # 49618
E~U1LDIN~ ~ t=t= EL IO-~ FT
LIN~ ELEVATION b-~l FT. SITE:
LIN~ I=1 P~/ATION b-~ FT. ZONING:
~ ~ ~.~.HIN. 2' HAX. HA~ATOCP~A SURVEYORI
I
I
I
CF~EK
AE~=PTIc . l
__ _ _ DEPARTMENT Or H~TH SE~ICES
~R~ FOR A~OVAL O~ CO~mUCTION FOR A
81~ F~M~W R ~NCE AND
- IOOO ~,AL ~,L.~ ~11G TANIC (,~T)
F41¢~4"1 I,.EAC,,HIIq~ POOL
L.C~'...ATION FOI~ ('~) ~' D'IA x 2'
HI~"I I..~._A~41N~ P~OL
EXPIRES THREE YEARS FROM DATE OF APPROVAL
of existing s~nitary system mu~t
depart~t requirem~t
YWM~_(~_ as proof.
~1~
LINE
(I~I~ELLIN~ I~ITH
F'U~LI~ ~TE~)
EXI~,TIN~, SANITARY S¥STEH TO
~ la. ef4OVl~
TEST HOLE
Water Line{s) M__US? Be Inspected By The
Suffolk Coun~ Dept. Of Health Se[vices.
Call 852-5700, 48 Hours I~ Advance,
To Schedule Inspection(s).
;ITE I: