HomeMy WebLinkAboutDoubrava, Derrick 041,0
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JUDITH T.TERRY ?` Town Hall, 53095 Main Road
TOWN CLERK ; N Z P.O. Box 1179
I
REGISTRAR OF VITAL STATISTICS ‘‘46/ Southold,New York 11971
�� � Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER - -1 4 s�aO��,i Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER �
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1544 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : PECONIC DEVELOPMENT CORP.
Address 1 : P. O. BOX 1010
City St Zip AQUEBOGUE NY 11931
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-96-51
Name Of Owner DOUBRAVA, DERRICK S.
Mailing Address 1 P. O. BOX 1010
City St Zip AQUEBOGUE NY 11931
Property Address 1 PARK AVENUE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 56.00 block 1 lot 2.008
Cross Street LONG CREEK DRIVE
Building Permit Number Cross Reference:
Issue Date: 9/19/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY =� G# �• Town Hall, 53095 Main Road
1
TOWN CLERK y P.O. Box 1179
u► Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O 47#
1 Fax(516) 765-1823
MARRIAGE OFFICER 'jijJ ���I
RECORDS MANAGEMENT OFFICER _ 0d , `1►� .. Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER "•~„ 'O."
,
OFFICE OF THE TOWN CLERK (
TOWN OF SOUTHOLDEP 1 6
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: September 13, 1996
!'/0
Transmitted herewith is a copy of application No. ,g,g. for a Cesspool/
Septic Tank Construction Permit submitted by:
Derrick Doubrava/Peconic Development Corp. •
Please review the application and location map and advise if the project
has received Suffolk County Health Department approval and if this office
may issue the permit.
Please complete the form below and return it to me.
Thank you.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE `�/
DISAPPROVE �
Comments: y,,,., ,5--",/....- � cJCf�U 4/$7,6—c; --f.20,1
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Signa ur-
9 /7 94
Date.
OFFICE OF THE TOWN CLERK „ ,`, ,..,• ,o
Town of Southold �_'' if.W. `°
Application NO.41,7
Judith T. Terry, Town Clerk ,
Town Hall, .S*10Main Road < Construction y,
SouthOkf NI*
York 11971 - Alteration
Tei i 0",” $10,40 - Residential I/
(S16) 789-1801 sta$, $25.00 -Non-Residential
TOWN OF SOUT i-HOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE TilS lq
APPLICANT NAME: i 1 t l,1(,GILL ' , C�'k:\-3 ' " Y'► IL'C s(//C tart C��l
AI PLICANT ADDRESS: B)? /6/D tc4 d - I 1l i
SEPTIC CESSPOOL
DESCRIPTION Of PROPOSED CONSTRUCTION OR ALTERATION
i; 1
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PRIPOSED CONSTRUCTION OR ALTERATION:
OWNER Of PROPERTY: i! 1 Ck �1
OWNER MAILING ADDRESS:%tel 3UX /0/0
OWNER PROPERTY ADDRESS: �� I`f��L Sv b
TELEPHONE NUMBER OF CONTACT PERSON: - 7ZZ--g7( Z
TAX MAP NO. : Section 5—(p Block di Lot Z,6
CROSS STREET: t c n' 6-- 6ax-e k- 7)
BUILDING PERMIT NUMBER CROSS REFERENCE:
110
Ds..
ignature o pl) scant
RECEIVED BY:
ler b rice
DATE: ,,1:31/4. /'
DR. ANY AL TEMATION OR ADDITION TO THIS SURVEY IS A VIOLATION
OF SECTION 7209 Cr THE NEW YORK STATE EDUCATION LAW
t_GREEK o HEREON ARE DICEPT AS PER FORTIS 7209-SUBDIVISION
THEALL A OOM.Y F
—1 SAD MAP OR COPES BEAR THE IMPRESSED SEAL Of THE SURVEYOR
WHOSE SIBNA TURE APPEARS ERE 1•
`O p ADDITIONALLY TO COAFLY W7TH SAD LAW THE TERM ALTERED Br
9 o Z MUST BE USED BY ANY AND ALL SURVEYORS UTIUZN6 A COPY
SURVEYOR'S MAP.
AND
265•I1n 'ROU6HT-TO-DATENN CONFUEWITH LAW.
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R.2S00, 1
`�?Gy tz,C (I/ o SYSTEMS
;vfUST
w rn li wATER,,., PLY DISPOSAL
NOVEMBER 13,1995.
7vCE S � ::utv;<��uyrtvi wtTa
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In
b' Dept. of iteSerac�es .38'5°, c, 70
N. 1° o SURVEY OF
p;� LOT 24
P Z "LONG POND ESTA TES SECTION CANE"
l¢5 i z w` CI) 7.-n
FILED DEC 27,1985 MAP NO. 8037
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o AT SOUTHOLD
, t, -.- C.R. pp'\ ..i+ ,2-------:;."----\ '0
prop TOWN OF SOUTHOLD
tore.` o o,
u,, _ s xe-�C L s ►�� SUFFOLK COUNTY, N Y.
,,, f 1000 — 56 — 01 — 28
�°�`" ,` , \ , Scale: 1".40'
June 4, 1996
D ; et.. 265•It \ ���e /9 199 (sCDH3 re��s �^
T. . ;�� R1 \ r0.
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r- SUFFOLKCOUNiYO®pAltl N1'Ql►'EIEA�.2RL�V,
.. c O
..% C O; — PERIIIIT FOR APPROVALOPt.OI R9U0lt Wt A
O
m SINGLE FAMLLP lSTDSMCItONLY
o, w DATE JUN 2 S 1996H o 0. -I
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APPROVED
,5P
S. e,'/rn q o+'n FOR 4 �, x�' ;'
o c ` + EXPIRE_c 1HREE YEI*ARS FROM DA fE OF APPROMfAL
/50'7, o The locations of wells and cesspools ,
l'ishown hereon are from field observations
CERTIFIED TO, D and or from data obtained from others. hEit
cjPo�Of.MF QT0
PECON/C DEVELOPMENT CORP. m
DERRICK S. DOUBRAVA m r ,�
ISLAND PROPERTIES OF SUFFOLK ; AREA = 40,143 sq. ft. ELEVATIONSTO DATUM.
EDe
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/ am familiar wi/h the STANDARDS FOR APPROVAL SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES IT-7,a> - -
AND CONSTRUCTION OF SUBSURFACE SEWAGE FOR APPROVAL OF CONSTRUCTION ONLY •� N y4-
°• 496�� �
DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES ( la LIC. NO. 496 =
' and will abide by the conditions set forth therein and on the R/0-96-0051 ?"""` 4IrAEI1 s • 6,i
perm!/ to cons/rucl. DATE HS. REF. NO. PECONIC SO"'"="71. P.C.
(516) 765 - 5020
P. 0. BOX 909 , ;,ti<;
1230 TRAVELER STREETc_•
APPROVED SOUTHOLD, N.Y. 1/971 .. "_..,• `.