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JUDITH T.TERRY �' Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
v. 4'71
� ; Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Oy ��,�1 Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER 0i•,1�`1►�O , Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER ,d°
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1647 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : GABRIELSEN HOMES
Address 1 : 19 DENNIS COURT
City St Zip RIVERHEAD NY 11901
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-95-0060
Name Of Owner WOODRUFF, BRUCE
Mailing Address 1 C/O PAT MOORE
BOX 438
City St Zip MATTITUCK NY 11952
Property Address 1 ARSHAMOMAQUE AVENUE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 66.00 block 3 lot 9.000
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 4/28/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY 1�� y1�'
, Town Hall, 53095 Main Road
TO CjI1 � ; y = i P.O. Box 1179
v. 41/1
�� Southold,New York 11971
REGISTRAR.OF VIT, ,,,.ST9TISTICS V Oy ��,��� Fax(516) 765-1823
MAR EWI ENCIER 4 O
RECORDS M4KAaltaiai� (]
T VFICER : •1 � '�►*•,•'' Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER / /i
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: April 16, 1997
Transmitted herewith is a copy of application No. 1717 for a Cesspool/
Septic Tank Construction Permit submitted by:
Bruce Woodruff •
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.
(,�/jcdcv
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recom endations:
APPROVE
DISAPPROVE
Comments:
RECEIVED
5 199 Signature
APR 2
3 ; 3 a Dated
Southold Townark
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,
OFFICE OF THE TOWN CLERK '
Town of Southold
]odiUh T. Terry, Town Clerk
Application N
-Fowl) ||aU 53095 Main Road ^ �� ^^^ '
' Construction
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P. O. Box 1179 ~'
Southold, New York 11971Af � Alteration
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Telephone °-/ if d " Residential
(516) 765-1001 - �'zzx'O'
Non-Residential
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TOWN 8FSOUTHOLD
i� �/�z�� \n,r~
Tl `L- �OUT}|0LD WASTEWATER DISPOSALDISTRICT Pero \0��~ ~�`
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� APPLICATION 81
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for
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CONSTRUCTION or ALTERATION PERMIT
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SEPTIC TANK or CESSPOOL
MAAit\ *
Permit No. � ���
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Fee �____________ | -- ��-�- ���� -u�~ / (
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DATE 4- "m \ & em Cl ' '- IC3|-CS
APPLICANT NAME: k �
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APPLICANT ADDRESS: 1)% \ \ 0
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SEPTIC CES�P0O[»��_
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DESCRIPTION OF PROPOSE RUCT|ON OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCAT ION OF PROPOSED CONST RUCT ION OR ALTERAT ION :
OWNER
OWNER
MAILING ADDRESS: „„,
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OWNER PROPERTY ADDRESS: No--# �� 4 (([>�-7
TELEPHONE NUMBER OF CONTACT PERSON : 4;)M
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TAX MAP NO. : Section \ 0 ��_«n Block [~ �� Lot --.__��_ _
CROSS STREET : 6»qhnR-�
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BUILDING PEEWIT NUMBER CROSS REFERENCE :
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A Signature of /\p |i-cao|---'— -
av6i_o_ryt .
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DATE :
, -r-7^-
erk's Office
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,
TERATION
TO 77W SUEVEY
AREA = 18,417 s¢ ft.•to tie lineCONTOµay AND ELEVATIONS ARE a SECTION MOD air IRE/sir STATE mums r uIIL "
OEM AS POI SECTKW 720S-SUInv)mKw t ALL C>ERTFICA TKINs
O
WWI AAF VALO FOR Utas IMP AND COPES T7 A' ML Y F
P CERTIFIED TOSOHM MATURE APPEARS '
O OM
VIRGINIA CROPPER
77.
CECELIA KEMPLER AAprlfl'L4LLY TO COMPLY MIH SAD LAW»E MAI ALTERED Er
PECONIC ABSTRACT, INC. \ LOST BE USED BY ANY AAO ALL SURVEYORS MOW A COPT r,
1 0 L 133,333 of ANOTAER SURVEYORS APAP. MOM SUCH AS'NSPECTED•AND
\��(A\' \ IIOU HT--TO-OATE"ARE NOT N CO PUAICE WIN THE LAW.
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• Q� '''`0 ' fbo r, ,/ i SURVEY OF
9s QG y LOT 19
' �` v , f. 'mss!
G6� 'v �� oo" '"l' Dwelling b,o�� MAP OF
��= `"alis ,3' oo' DWe b "BEIXEDON ESTATES"
M1 S i.O �� R ' ' -•��r= FILED MAR. 16, 1946II
L NATE FILE NO. 1472
�� I puBGIG bale
A T SOUTHOLD
RaCirtIV--4•T) GTOWN OF SOUTHOLD
' }° SUFFOLK COUNTY N.Y.
Ism
1000 - 66- 03 - 09
APR 'A 1995 Scale : 1"= 30'
The locations of wells andsces)spoo/s ,r_
shown hereon are from field oblervotions Dec. 19, 1994
S.C. DEPT. OF and or from data obtained from others. Mir. 1 (contours)
SERVICES 5 . 3.f. r,:.,S Yni
HEALTH :. . �,,.x.ld , �'#_t hl(s
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: . .! .. .,':1';'i ,tl`;M I':.fill�nl:iAi"s=-ii'FJi!!. ,e. of -:-fio i6.0,.. ♦E .3 J N
���E✓ SUFFOLK COUNTY DEPARTMENT OF M EALTH SERVICES CERTIFIED TO • p c�T/rte �I �.)/ //P7/
!', .FOR APPROVAL OF CONSTROCTI.ON ONLY
< ; V/RG/NlA CROPPER
i1 % i `' Msri. T4: CECELIA KEMPLER Z-6�- ' :r
(i+ • 7 .f. •<- ntr S. IC. NO. 49618 r RIO,0 -OO�oG PECONIC ABSTRACT INC. N-77 `4p)2-;
DATE 9 5 4s. REF. No. I am haw WI the STA1IDARDS FOR APPROVAL
'EC. S ''.VE..1f'RS P C.
AND CONSTRUCTION OF SUBSURFACE SEWAGE
'161 - . ,) J DISPOSAL SYSTEMS FOR SIM6LE FAML Y RESDENCES
', / and NAI ad(de by the set far/h .hi and on /he
2. O. :,e 909' s;'1
MIN r •Z- 490°.* ,- -'vEQ,� _ permN I collelrrAe
iOUTH e,r 0 • 0 c2/I4/93( REVISIONS) �j •dli
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94-366