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Home My WebLink AboutMalone, Robert G o~~SUFFO(,p~0 ELIZABETH A. NEVILLE, MMC Town Hall, 53095 Main Road TOWN CLERK p P.O. Box 1179 Z Southold, New York 11971 REGISTRAR OF VITAL STATISTICS O .F Fax (631) 765-6145 MARRIAGE OFFICER Telephone (631) 765-1800 RECORDS MANAGEMENT OFFICER wwwsoutholdtownnygov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLE TOWN OF SOUTHOLD D E C E ~ U TO: Southold Town Building Department APR 2 D 2014 FROM: Carol Hydell, Southold Town Clerk's Office KHOPT. DATED: April 2, 2014 TOWN of SDUTuDID RE: Cesspool Construction/Alteration Application Transmitted herewith is a copy of application No. 4229 for a Cesspool/Septic Tank Construction Permit submitted by: Samuels & Steelman for Malone 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 and location map of the project cited above and make the following recommendations: APPROVE DISAPPROVE Comments: t Signature PK O 3 Dated . ~ ~gOFFO(,~c ELIZABETH A. NEVILLE Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 Z REGISTRAR OF VITAL STATISTICS Southold, New York 11971 ~ ~?f MARRIAGE OFFICER • `iC Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER y~f 0~ Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION CONSTRUCTION or ALTERATION PERMIT l CESSPOOL or SEPTIC TANK I Residential @ $10 V or Non-Residential @ $25 _ Application No. (G2~ 'p. Permit No. Applicant Name OL C ep (It hya ~cfc Applicant Mailing Address_ _ L66 3~ AA lNl W-J• Ck tc L(gTq~ Septic Tank ? or Cesspool ,,,I!,, Brief Description of Proposed Construction or Alteration ~ ew Ve_s I'A"Icz t_y (1Q[// +q,+'k~1 5 ~ {-C-4Yt Tb2v^,~'(` ~ (~-S ip2VLtiv~x` Location of Proposed Construction/rA_lteraattion: Owner of Property: y~19~'t G- { k \ ,X/ p Owner Mailing Address: f 6w( i J D y l t l V .Ul 7 Owner Property Address: 3 &D 04k qt) kv e - o AID Name and phone number of contact person Tax Map No::/(Qp0 Sectio~n~ X59 Block Lot _1o Cross Street #Cecn w (~t S NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL Signa a of Applicant Date Received by: ' 61KAVC WNC C=V^I ivn Y1" r i ADDRESS SOUTHOLD, NY 11971 r I',MIN 2' MAX I-' MIN 2' MAX " ...r OWNER: ROBERT G. MALONE ITOP OF POOL 1955 FT SOUTHOLD NY 11971 SEPTIG LEAGHINS SITE: 155,276 at = 3.565 ac TANK IE. +14.9' POOL 50T OF POOL 1955 FT ZONING: R-80 IE. +19.22' SURVEYOR: NATHAN T. CORWIN _ GROUND WA'!ER ELEV +8A FT PO BOX 16 e 8~-~° 3' MIN JAMESPORT, NY 11947 License • 49273 'IC PROFILE RESIDENCE Date' 10/14104 RECEIVED LOCATION MAP C V 05 13 2010 u SUFF. CO. HEALTH SERVICES u OFFICE OF WASTEWATER MGT. ITE t C e ~ - ~3 < C C TEST HOLE EXCAVArrory (rv f~ NO SCALE BY MARK McDONALD GEOSCIENCE e BYOB NrrAtYtGtUlf3~1 SOUTHOLD, NEW YORK 11971 H ALTH D T TEST HOLE DATA 7119110 ELEV. 18.5 w_ 3 FT. Brown Silty Sand S „ T TER NETLANDS AS 7FL Brown Sand Silt ML s 4 / BY GIN. BOWMAN LAND < r L VI , INC. 10.5 FT, Brown Clayey Sand SC 20 FL I Water in Brown Clayey Sand SC Water in Pale Brown Fine 28 FFT, I to Medium Sand SP WATER ENCOUNTERED 10.5 FT BELOW SURFACE GROUND WATER ELEV +8.0 fflmrermff~ ~U BU~fid~K mmwlwr- N o~ JULY2 20 I ~l _ r^Ji.Ti~ SFRV/(,'~S. 1„ e TYPI AL -2- 25p4 c'?J "1 of NEW w g~PA~ 5 C. S gM OI'f SITE F - 30 ~O 183 _VA4 SCD S SUBMISSION SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES FOR OFFICE USE ONLY OFFICE OF WASTEWATER MANAGEMENT 360 YAPHANK AVENUE, SUITE 2C, YAPHANK, NY 11980 Health Department Ref. No. (631) 852-5700 OR HealthWWM@suffolkcountyny.gov APPLICATION TO UPDATE AN EXISTING PERMIT TO CONSTRUCT SEWAG - W Q$AL.AND W.9TXR - SUPPLY FACILITIES FOR A SINGLE FAMILY DWELLI G. REFER TO REVERSE SIDE OF THIS FORM FOR INSTRU IONS FILL OUT ALL APPLICABLE SECTIONS OF THIS FORM. ALL SIGNATURE MUST f'I9INA} Type or print firmly to ensure legible copy $ ` L`3 tl FOR ALL RENEWALS AND TRANSFERS SUFF. CO. Hl p tir(_, rr. ~ ry i S EXISTING HD REFERENCE NUMBER: Lf.6- Tax Map No.: District S~tion 0Block 'Z Lot ( 000 (p Name of Current Applicant: p~9e1^ Tel#_ fr Mailing Address: ?d ST5 C ty State N~ Zip (~Q 7r Email Address: ~Q~,~ e, • b 1 AJ,0 Name of Current Agent: SaMLtrclSd g;00JWa44 AVCh Tel#: 6 1 734 (QgoS Mailing Address: 2g13SfAtK City.,t~"~ toe StateN~Y Zip ,tC~3S' Email Address: t00t ~t~tlvelS S"~e~lwut~t• +LIDH1 DATE OF ORIGINAL APPROVAL: g I (b `If more than 6 years old and SCDHS site inspections have not been performed, a new application will be required FOR TRANSFERS WITH PREVIOUS APPLICANT/AGENT PERMISSION Name of Previous Applicant/Agent: Tel#: I hereby transfer all rights and interest in the above referenced permit to the new applicant named above; Signature of Previous Applicant/Agent: Date: FOR TRANSFERS WITHOUT PREVIOUS APPLICANT/AGENT PERMISSION Name of Previous Applicant's Tel#: Architect/Engineer/Surveyor: I hereby authorize the above named current applicant to use the previous applicant's survey/site plan for this project prepared by me; for the purpose of transferring the above named reference number and its site design. Architect/En ineer/Surve or's Signature: Date: FOR ALL RENEWALS AND TRANSFERS Application is hereby made to [TRANSFER, ENEW (check applicable) 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 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 punishable as a misdemeanor pursuant to 5210.45 of New York State Penal Law." Signature of Current Applicant/Agent Date La 3 I?~ Print Name of Current Ap icant/Agent Title l Samuelei, A.A. DEPARTMENT USE ONLY Permit is Transferred/Renewed Until f z 2,01 Number of Bedrooms Approved - Signature of Department Representative Date I ) WWM-104 (Rev. 03/12)