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SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3984 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : J P MODULAR HOMES INC.
Address 1: 131 HICKS STREET
City St Zip BROOKLYN NY 11201
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. REF #R10-07-0114. FINAL APPROVAL REQUIRED FROM
THE SUFFOLK COUNTY HEALTH DEPARTMENT.
Name Of Owner MARK BAXTER
Mailing Address 1 131 HICKS STREET
City St Zip BROOKLYN NY 11201
Property Address 1 5805 MAIN BAYVIEW ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 78.00 block 7 lot 5.006
Cross Street SMITH DRIVE SOUTH
Building Permit Number Cross Reference:
Issue Date: 10/18/10 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE,RMC, CMC � � 0 Town Hall, 53095 Main Road
TOWN CLERK l l�[ , P.O. Box 1179
v, Southold, New York 11971
REGISTRAR OF VITAL STATISTICS G ,1
MARRIAGE OFFICER . - ••• ,1 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICERl Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER `OyCOR ,,�,III1°� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD V
ECIE [I
TO: Southold Town Building Department
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FROM: Carol Hydell, Southold Town Clerk's Office OCT 7 2010
DATED: October 7, 2010 BLDG.DEPT.
TOWN OF SOUTHOLD
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 3984 for a Cesspool/Septic Tank Construction
Permit submitted by:
J. P. Modular Homes, Inc.
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.
Carol Hydell
* * * * * * * * * * * *
I have reviewed the application and to tion map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Final approval required from the Suffolk County Health Department
Signature
/0/r
�C
Dated
. ELIZABETH A.NEVILLE - i lAt OG* Town Hall,58096 Main Rot
TOWN CLERK • 1 ".., . P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 0. I i Southold, New York 11971
MARRIAGE OFFICER t.CP 11 Fax (681) 765-6145
RECORDS MANAGEMENT OFFICER x:440! 0*. oil Telephone (681) 766-1800
FREEDOM OF INFORMATION OFFICER �,•' southoldtown.northfork.ne
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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 @$25Application No.3 ? V y
\ Permit No.
Applicant Name TT hd dL,,(Rf- 1-_(,,,...._,„ 1
hc, ,
Applicant Mailing Address ( 3 1 S f -.m± ' 764..1 N ,s1), l/ZO(
Septic Tank. or Cesspool ,) J
Brief Description of Proposed Construction or Alteration v e,..,1 �' , l� 4Ad.,,, 1 SF IjZ
Location of Proposed Construction/Alteration: )
Owner of Property: I`1a.,�t� j ' [c,/ LtJ�) ric�'^1Gvr l 0v14,t: Inz. •
Owner Mailing Address: 1 3 ( ;�4r Str�4-
_ q,/ . 1 � ,, &)Y. 117- i
Owner Property Address: 5-9,<--).S- tick x-,_ L�-x
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a 1� N ,`(. j1n-))
Name and phone number of contact person L- ?c.-1 6zw,9.V-.
Tax Map No: Section - Block e- Lot CO ,
Cross Street 5„..,..A-C),:)<. Od a -2
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY A H HEALTH DEPARTMENT APPROVAL
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Sign:tore o Applicant-r-., d� I�� e� ..f -to--
Received liy: J n° `l
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TEST HOLE Young & Young 1• F'<
AREA = 2.3664 ACRES 9N
FROM FILED MAP 400 Ostrander Avenue, ,
N UPLAND AREA = 1.1781 ACRES Riverhead New York 11901 €�8
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0.0' THIS PLOT PLAN DEVELOPED UTILIZING AERIAL 631-727-2303 1°29
.1 MIXED SAND • SUBDIVISION - "MARK BAXTER" FILED IN THE OFFICE tc�
AND LOAM PHOTOGRAPHY, CONVENTIONAL SURVEYING OF THE CLERK OF SUFFOLK COUNTY ON NOV. 14, 2006 Howard W. Young, Land Surveyor tsa.5
TECHNIQUES AND RECORD DATA. be <
A5 FILE NO. 11464 Thomas C. Wolpert, Professional Engineer <a
1.0. Robert C. Tast, Architect x�`�
GREY CLAY • VERTICAL DATUM = N.G.V. DATUM (M.S.L. Ig2c1) Douglas E. Adams, Professional Engineer €Ito
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1 °�— °'°�H°"a J I G 1=.a.2I�•� J AMENDED BUILDING PERMIT DATA JUNE 04, 2010 • ��
e AMENDED BUILDIN6•RI �EIVED MAY 05, 2010 Was
PPR. 24, 200g
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'`LEGEND `.ater Una ;' MUST Be Inspected By The DEG. 12, Zoos��� CT. b, 2008ufflk County ept. Of Health Services. I .�� .�—� . PATER ing UG R E -1�5 -57 � �.,,�T.1.� �, F s °° JUN092010 ?°; oa s} L6 = Lo►•ER BRAVE l lours i Advalice, �,O �€GGT. 26, 20001SF°° + 1.2 • SouNDINGS tTef�llle section(s). } {,,,�,,,G PROF,,,,F MAP PREPARED SUFF.CO.HEALTH SERVICES AUG. 8, 2007a/ •
+ 1.10 =SPOT SPAVe �XIV HIS I Ot ICE OF WASTEWA MGT. �\ �` OSCALE: I"=100' �"Q•MONUMENT ••MONUMENT FOUND Q. .STAKE SET A•STAKE FOUND O =LATH SETvIEll t O DIRECTION C•CHIMNEY RO•ROOF OYER5•STOOP cE=CELLAR ENTRANCE ``, .SEE A't CACHED SPECIAL CONDITION -�B NO. 2010-0100--Q = ` - _ - _ DW6. 2002_0266_002�00"I_023g—bp—plan_B_r8I OF 3
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