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SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3490 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : JERRY & LINDA MATEJLA
Address 1: 94 FULTON BLVD.
City St Zip COMMACK NY 11725
Descripton of Proposed Construction or Alteration
-RENOVATION OF FIRST FLOOR & SECOND FLOOR ADDITION
-FINAL APPROVAL REQUIRED FROM THE SUFFOLK COUNTY HEALTH DEPARTMENT
Name Of Owner SAME AS ABOVE
Mailing Address 1
City St Zip 0000
Property Address 1 1300 STROTTSON ROAD
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 103.00 block 10 lot 2.700
Cross Street BALDWIN DR.
Building Permit Number Cross Reference:
Issue Date: 12/11/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
se'
ELIZABETH A. NEVILLE e se'o Town Hall, 53095 Main Road
TOWN CLERK * P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ,i Southold, New York 11971
MARRIAGE OFFICER IttsFax (631) 765-6145
RECORD .MAN.A _ MENT OFFICER �lirco pri 01oI Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER + of southoldtown.northfork.net
sir
I ,6 2n6 OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: t
FROM: Lynda M Bohn, Southold Town Clerk's Office
DATED: November 15, 2006
Transmitted herewith is a copy of application No. 3646 for a Cesspool/Septic Tank Construction
Permit submitted by:
Jerry & Linda Mateila
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.
Lynda M Bohn
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: � c
Si ature
ft/7/04
Dated
4s3IOL4'Is ;
ELIZABETH A.NEVILLE k',h�O �G `` _Town RowHall, 53095 Main Ro
TOWN CLERK tel* P.O.Box 1179
REGISTRAR,OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER 11Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ` y �` i� Telephone(681)765-1800
FREEDOM OF INFORMATION OFFICER O'� * � ''� 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 Applicatio• o,
Permit Nt ►,eel
Applicant Name \7-- - Y ci0 Z—l/fr-7)t .�
Applicant Mailing Address
CDMiin- 6Y /lam
Septic Tank or Cesspool %)1._
Brief Description of Proposed Construction or Alteration e.=1"(}V.4'lta v D f
11l�S7 r-' O ii- 7 7) S e9 N)) �1�/77 ov-
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address: / F14,1.--7'a A- (54 )V
Owner Property Address: /A V S7 i7S '
1/73 'c
Name and phone number of contact person
Tax Map No: Section /O3 Block / 0 Lot 2 7
Cross Street bbl)W SN '17L
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQ I'.' URVEY H HEALTH DEPARTMENT APP ; S V
If .
igna e of Appli Date
Received by:
• TEST HOLE DATA
(TEST HOLE DUG BY McDONALD GEOSCIENCE SURVEY OF PROPERTY
ON OCTOBER 27, 2005)
EL Zs� SITUATE
jBROWN SILTY SAND SM NEAR PECONIC
z5' TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
DIEING of S.C. TAX No. 1000- 103-10-27
. - PALE BROWN FINE TO MEDIUM SAND SP LASES PUBLIC
WATER) ���
I' ll SCALE 1 "=30'
_ q HENRY AO/F
gQ aOCZEx JANUARY 3, 2000
/ it23 16.3 S 82.26 EDrr
q / ., If A- BOCZE m
,,- 'S0 E _ _16 K �mi U
1
NOVEMBER 22, 2005 ADDED TOPOGRAPHICAL SURVEY
"'[,.
AAA 15.4 .5,d IN it= /�°i t'" .,,y ^ 1 / S AREA = 15,587.24 sq. ft.
'• 10.3' ad N
Io o
. '�x 15.7
D . / O (TO BULKHEAD)
/ 14.4 163.�5 0.358 ac.
�— WATER IN PALE BROWN ONE TO '�..0 / �:.:�+ �'411/0'
�j :-.;..i.. _ ^� 1—�16:� / �''/ lrAgli �>�•�
MEDIUM SAND SPII ♦��♦ f
— Q i / / �; ;`. := ; 1000 / /0 �{�I /'m NOTES:
w T.C,j�1 1........, / I I , / m/ 1. ELEVATIONS ARE REFERENCED TO N.G.V.D. 1929 DATUM
4, cow.cage• +n� STORY- ::' e / M
1r a: : ��_ '. 1.:-:: I ry / EXISTING ELEVATIONS ARE SHOWN THUS: 10.Q
0 - B.W,10 '";. rt;', : -FRAME:_:::X_�� P • * I I / I
11, 1.!:-P HOUSE::::::: "� T 5 N 2. MINIMUM SEPTIC TANK CAPACITIES FOR 4 BEDROOM HOUSE IS 1,000 GALLONS.
Z Z I ....on., / ' H I ':` , • °F • /'.9 1 TANK; 8' LONG, 4'-3" WIDE, 6•-7• DEEP
v _ •ORCH jt "::::2nd STORY,:::_ / 44: 1 JJm 3. MINIMUM LEACHING SYSTEM FOR 4 BEDROOM HOUSE IS 300 sq ft SIDEWALL AREA.
a 0 w = v-' ?A�� •i ai .ADDITION:•:: /
2 POOLS; 6' DEEP, 8' dia.
•
Z1 1 yal, t. - /
��������� PROPOSED EXPANSION POOL
1 Ar - r ,s-,,........„.,,.....7%.:,:::::..1 . ---7.,„ / / c,/
�' a 12.5 ,��c a -: - / 1 / i 1/ - PROPOSED LEACHING POOL
E'+ `-4 N-- --J-- / W1"" 1,3 19.0' a / / /I S �(
/ EXT. \ 121 r I x/ ,)1* / 5Vc4, / / / ,� V ��� PROPOSED SEPTIC TANK
�7 /2,1 TEsr HOLE / - )-z / '- w/ / X�" //°'„ // 4 J 4. THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD
_L� _ _ ' _-3,42.2____
12.5 / '° FAME / ! Q g' o' / / W �' OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS.
x _ — GFA j5 0 NN P/4r / l'T 5. FLOOD ZONE INFORMATION TAKEN FROM:
/
E.-- �� szs 1a 4' f] / / ' /, ( 7 FLOOD INSURANCE RATE MAP No. FROM: 0164 G
It
\ I\ 11' / P d //1 I / / poi ���. ZONE AE: BASE FLOOD ELEVATIONS DETERMINED
LL0- I \ \ \ 11 ` I go. I/ % /1\'
O / �+:�y '�� ZONE X` DEPTHAREAS OFFLESSS THAN 1 R FLOOD;
OR WITHDRAINAGE 4R AREAS OWITH LESS THAN AVERAGE
x I= '-*° '"
1 SQUARE MILE; AND AREAS PROTECTED BY LEVEES FROM 100-YEAR FLOOD.
n / I I =' \\ \ \\x \NI \ x-2-6 1 ^1 ' ` I . 1 ZONE X. AREAS DETERMINED TO BE OUTSIDE 500 YEAR FLOODPLAIN
.
/zil \ o.rW x a>t
•
BALDWIN ' iiN 84'54'20;- \►= �j__ _, 0m' c
PL w 0 9 I •
ACE M NOF � 40
138.94 ., h„
A. MADELE E I i
IiAUSER PREPARED IN ACCORDANCE WITH THE MINIMUM
DWELLING s STANDARDS FOR TITLE SURVEYS •S ESTABLISHED
(USES PUBLIC WATER) BY THE L.I.A.L.S. AND APPROV AND ADOPTED
FOR SUCH USE BY THE NEW SRK STATE LAND
TITLE ASSOC.. -
��.c 0FNEW ►' I
Abandonment of e ist, s �� }s st d b • G QN A- IN• y.14-
t rs.�Ta1ta YL 5C
comfor�na ec i 3ep
)r51t l
completed form WWF: .3 �' >� '��'
O
\ (t��;"► 1(�11-
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SUFFOLK COUNTY CEr R :Anti`O :LTH SERVICES S'ja N.Y.S. Lic. No.
{, ''N FORA
PER'b�I& r'�b:i �€ 1E' Ki��'a-3 �� 6- ,3+'��E : ON UNAUTHORIZED ALTERATL N-OR ADDITION
S' N,:3 e"�o r1. N ,;r..r;..� TO THIS SURVEY IS A VIOLATION OF
�I:'<<y3 a •}-`1 e 1L ' 7<vt +"dj` SECTION 7209 OF THE NEW YORK STATE c
EDUCATION LAW. Josep A. I ngg enc
b. l c�}l^ V V
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR Land S u rve y o r
PAT:::4_17
p .� ,� n,. ' CERTIFIED TO: EMBOSSED SEAL SHALL NOT BE CONSIDERED
t:i„�1 spy H a `.y� D,` 0 OC. -0 -X TO BEA VALID TRUE COPY I
A' FIRST AMERICAN TITLE INSURANCE CO. OF NEW YORC
p PECONIC ABSTRACT CERTIFICATIONS INDICATED HEREON SHALL RUN
P �4 i S e`w ,�� i ONLY TO THE PERSON FOR WHOM THE SURVEY
JERRY MATEJKA IS PREPARED, AND ON HIS BEHALF TO THE
TOTAL 3V. F 114. 4'.T^'�s.yp ;ra
LINDA MATEJKA TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys — Subdivisions — Site Plans — Construction
i+�TiL yvuvu.Fe 1I�i+.�.a,�`+sv :l LENDING INSTITUTION LISTED HEREON, AND11
TO THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-2090 Fax 631 727-
v1911aco s'i.sacc vE=']RQ 1;Pe1?,1 E?G`3'1"(IF A.PI=RQVAL
TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE.
11
OFFICFS IOCATED AT MAILING ADDf
1