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• ELIZABETH A. NEVILLE ,�� y� • Town Hall, 53095 Main Road
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TOWN CLERK t y Z ; P.O. Box 1179
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Southold, New York 11971
REGISTRAR OF VITAL STATISTICS `;O
MARRIAGE OFFICER y� 0��of1, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER . Ol � �a,,,t Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �,,,,.���� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3258 R Residential x Non-Residential
Fee $ 100.00 Septic x Cesspool
PERMIT ISSUED TO:
Name : ROBERT'S CUSTOM HOMES
Address 1: P 0 BOX 372
City St Zip WADING RIVER NY 11972
Descripton of Proposed Construction or Alteration
CONSTRUCTION OF NEW SINGLE FAMILY RESIDENCE
FINAL APPROVAL REQUIRED FROM THE SUFFOLK COUNTY HEALTH DEPARTMENT
Name Of Owner PROIOS, JOHN
mailing Address 1 530 BAY AVE
City St Zip EAST MARION NY 11939
Property Address 1 SAME
City St zip 0000
Tax Map No. section 310.00 block 8 lot 9
Cross Street MAIN ROAD
3uilding Permit Number Cross Reference:
,?" °7 4,;r` 1
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Issue Date: 1/27/05 A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ��� y1` Town Hall, 53095 Main Road
TOWN CLERK t viaZ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS `\O 471 Southold, New York 11971
MARRIAGE OFFICER 4•,.
c X11 Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ; Ol 4, ' .e Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER . , ,•""°° southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: November 17, 2004
Transmitted herewith is a copy of application No. 3401 for a Cesspool/Septic Tank Construction
Permit submitted by:
Roberts Custom Homes
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: V' .,,`ea
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Signature
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Dated
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ELIZABETH A.NEVILLE ���h`t`� y Town Hall, 53095 Main Road
TOWN CLERK yT P.O.Box 1179
REGISTRAR OF VITAL STATISTICS � yy, �� Southold, New York 11971
MARRIAGE OFFICER : � �, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER V** 40*oe Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER O'( * �a•'� 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. ✓ 1
Permit No.
Applicant Name R)\J2✓s QS +0-4('') ` S
Applicant Mailing Address PO X 2--
Wad)
Waw n e e!2-- ( f
Septic Tank or Cesspool
Brief Des riptio f Proposed Construction or Alteration Q C7(\S-(-v'U r &.)
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Location of Proposed Construction/Alterat'
Owner of Property:
Owner Mailing Address:
Owner Property Address: 5 U kc.' 74e—
ff 5-1- (Yl C/1_t( cn'\
Name and phone number of contact person U l c -c —1-04-4n 2 r c11
Tax Map No: Section 3 / Block Lot q
Cross Street 1 r 1 /A. ��
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WIT - ALTH DEPARTMENT APPROVAL
\rj-eAA' 1 \l \OP `U(-11
Signature of Applicant Date
/►�Received by: � p �,
N AT EAST MARION
TOWN OF SOUTHO,
SUFFOLKCOUNTY, N. Y.
.� 1000-31-08-09 1.
11 -‘1‘
SCALE- 1'=30' 11
61
,. JUNE 21, 2004 1
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES o. 1-1-4
PERMIT FOR APPROVAL OF CONSTRUCTION FOR A 4
j SLE FAMILY RESIDENCE ONLY _.6P �lk Ae.i e—Z.
DATE/V/ 7/ S REF.NO. n ••D b IV
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.� lis 13 •5 %� ° 71.-
- APPROVED„ �� i � o 6
FOR MA Cesium OF,BEDROOMS cke' // t> �^ Vor
44
I. EXPIRES THREE YEARS FROM DATE OF APPROVAL 10 l�h° �I/ � •
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15 of
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7 Z '� TEST HOLE DATA tv
NICj. ; 6/29/04 CO --
S.‘ !36 rDARK BROWN LOAM a -7 r
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,..,,,,• a. BROWN SILTY SAND SM •-4.
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I am familiar with the STANDARDS FOR APPROVAL O -y. �� Ls :56 t1�
AND CONSTRUCTION OF SUBSURFACE SEWAGE c % 0
DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES fr. ,t
and will abide by the conditions set forth therein and on the ` O ?ALE BROWN TO / SAND
permit to construct. ''fi O.
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The location of wells and cesspoo/s shown hereon are Oi E`V
from field observations and or from data obtained from others. IP EW),
o`''''''1. Qrd�',t
ANY AL TERATION OR ADDI TION TO THIS SURVEY IS A VIOLATION N
OF SECTION 7209 OF THE NEW YORK STATE EDUCA TION LAW. s " R= 4,
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS /45114te:
+HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF 'l� N. Y.S. LIC. NO.
SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR
•
MIOSE SIGNATURE APPEARS HEREON. optC. . . YIRS, P.C.
Elevations referenced to an assumed datum.
*4„,,,.. . FAX (631) 765—�'
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:: ±/MTTAREA=11,218 SQ. FT. SOUTHOLD, N. Y. 1197104—
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