HomeMy WebLinkAboutCohen, Clifford o��SUFFO�,�co
ELIZABETH A.NEVILLE,MMC ht. r/y Town Hall,53095 Main Road
TOWN CLERKo= P.O.Box 1179
Cie Z Southold,New York 11971
REGISTRAR.OF VITAL STATISTICS p • Fax(631)765-6145
MARRIAGE OFFICER 'y ��' Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER �j �a
FREEDOM OF INFORMATION OFFICER southoldtownny.gov
OFFICE OF THE TOWN CLE
TOWN OF SOUTHOLD OCT Z $ 2014 +rj `
TO: Southold Town Building Department
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FROM: Sabrina Born, Southold Town Clerk's Office
DATED: October 27, 2014
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4275 for a Cesspool/Septic Tank Construction
Permit submitted by:
Clifford and Leslie Cohen
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: Final approval required from the Suffolk County Health Department
2
Signature
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Dated
o�suFFot,r�o
ELIZABETH A. NEVILLE �`1` G.y Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
C4 Z Southold, New York 11971
i REGISTRAR OF VITAL STATISTICS O Fax (631) 765-6145
MARRIAGE OFFICER ,y • ��
RECORDS MANAGEMENT OFFICERTele hone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �O'� �a southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
i
V SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 V or Non-Residential @ $25 Application NoAk'7-5
Permit No.
Applicant Name --k aL A Leif t'C
Applicant Mailing AddressZO7
Septic Tank or Cesspool r
Brief Description of Proposed Construction or Alteration cc.y $! QP&LeAkkz
Location of Proposed k Z Construction/Alteration: �
Owner of Property: f Z 1�'oyj c.�-c.c� 11 C CO
Owner Mailing Address:
Owner Property Address: 11+
Name and phone number of contact person
Tax Map No: Section Block 3 Lot -S—
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SU Y WI H EALTH DEPARTMENT APPROVAL
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Signature of Applicant Date
Received by:
N
/ A SUFFOLK COUNTY DEPARTMENT OF HRUCT ON FORA SERVICES
PERMIT FOR APPROVAL OF CONS
Qn SINGLE FAMILY RESIDENCE ONLY
�7lFh. 0 00 (H.S.REF.
PATE
APPRO ED
Zone FOR
um OF BEDRaO
EXPIRES T REE.YEARS FROM �JATE Or APPROVAL
AE 7 _ - �--
y
est
I •N� WATER LINE(S) MUST BE INSPECTED BY THE
J SUFFOLK COUNTY DEPT- OF HEALTH SERVICES,
CALL 857' 7T' =48 HOURS IN ADVANCE,
SCHE ULE INSPECTION(S).
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LIC. NO. 4:
CLIFFORD COHEN YORS, P.C.
LESLIE COHEN ( —5020 FAX (631) 765-1 i
INSIGNIA NATIONAL TITLE AGENCY, LLC P.O. BOX 909
1230 TRAVELER STREET
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TERMED BY TEST HOLE DATA
BY McDONDALD GEOSCIENCE
IN DECEMBER 24, 2013 1/20/14 1:50PM
WAL EL 9.2'
DARK BROWN LOAM OL
0.5'
.NCES
BROWN SILT ML
rein and on the — 25'
BROWN FINE TO COARSE SAND WITH 10 X GRAVEL '
,eon are — 5'
lined from others. PALE MOWN FINE TO COARSE SAND SW
A 7701 FLOOD ZONES FROM FIRM EL Z1 _ V
AW. 36103CO068H SEPT. 25, 2009 W"
FICA7701VS WATER IN PALE BRM FINE TO COARSE SAND SW
ONLY If ELEVATIONS AND CONTOUR LINES ARE
SURWYOR REMFEld'aV TO NA VD DATUM.
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