HomeMy WebLinkAboutGrocke, Ed SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3921 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : WAYNE GOLDBERG
Address 1: 15 KINGSTON ROAD
City St Zip MT SINAI NY 11766
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 #R10-09-0059. FINAL APPROVAL REQUIRED FROM
THE SUFFOLK COUNTY HEALTH DEPARTMENT.
Name Of Owner ED GROCKE
Mailing Address 1
City St Zip FL 0000
Property Address 1 1015 FOURTH STREET
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 117.00 block 8 lot 3.000
Cross Street KING STREET
Building Permit Number Cross Reference:
Issue Date: 1/12/10 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
.
d AN% F SOij,'yo
ELIZABETH A.NEVILLE,RMC,CMC I As, l0 .i Town Hall, 53095 Main Road
TOWN CLERK i sig illiz P.O. Box 1179
REGISTRAR OF VITAL STATISTICS N ie , Southold, New York 11971
MARRIAGE OFFICER $„,- .1 # Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ��V #11
Telephone (631) 765-1800
_
FREEDOM OF INFORMATION OFFICER .‘$0,,
.COUN 1(,� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department 1.1_,,,, , 0
FROM: Carol Hydell, Southold Town Clerk's Office
DEC 3 0 200P
DATED: December 29, 2009
BLDG.DEPT.
RE: Cesspool Construction Application TOWN OF SOUTHOLD
Transmitted herewith is a copy of application No. 3921 for a Cesspool/Septic Tank Construction
Permit submitted by:
Wayne Goldberg for Ed Grocke .
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 location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Final approval required from the Suffolk County Health Department.
` /_1
Signature
O/ O b /O
Dated
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• , 0�OFF.O
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• ELIZABETH A.NEVILLE i'i'Z` Town Hall, 53095 Main Roe
TOWN CLERK . . , . P.O. Box 1179
REGISTRAR OF VITAL STATISTICS yyy
Southold, NewYork 11971
MARRIAGE OFFICER .' . ��� Fax (681) 765-6145
RECORDS MANAGEMENT OFFICER �_,,��,, �i Telephone (681) 765-1800
FREEDOM OF INFORMATION OFFICER L.ell � `�..' southoldtown.northfork.nei
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 +V or Non-Residential @$25 Application No. 361.01..(
Permit No.
Applicant Name iU! Go%/ r
t
Applicant Mailing Address `Jr l�/hl Sn c'� 414- Si 4 a r
Septic Tank t/ or Cesspool
Brief Description of Proposed Construction or Alteration f2.Qf,U C DyLSi-r/,6C_460/'7
Location of Proposed Construction/Alteration:
Owner of Property: Gro C k e_
Owner Mailing Address: For, d�
Owner Property Address: /O/5-- u r-,h S-�
Name and phone number of contact person V al/iJ Lo/i/ 9
Tax Map No: Section 7/ 7 Block S Lot 3
Cross Street V,vi / S
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SUR Y WIT ALTH DEPARTMENT APPROVAL
. ignatur�Ap licant Date
Received by:
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES ,
RO`,A,i Or CONST:=L' T :I FOR A KING
PERMIT FOR Xt^ '. �� f i r STREET
SINGLE PAI...L ii '1 4,1'11C.4,!1'tl L..� -____
DATE Oq i":. 11 kll'�_...._ -['�C.h C ,
APPROVED "�'`Q. ......._ ...
('O€2 MAXIMUM O , SEDROOMO
EXPIRES THREE YEARS FROM DATE OF APPROVAL _/as.
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EXCAVATION INSPECTION REQUIRED
FOR SANITARY SYSTEM �Bvc iv T� D
EY HEALTH DEPARTMENT
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51. WATER W BROWN AND SURVEY OF PROPERTY
GREY CLAY CH
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WATER IN BROWN FFINEHSE. AT NEW SUFFOLK
SAND SP
57. • TOWN OF SOUTHOLD
SUFFOLK COUNTY, N Y
, "O' , 1000 - 117- 08- 03
Scale: 1"- 20'
1 AVERAGE SETBACK = 6.7' z.'• JULY 20, 2009
JULY 3a 2009 (REVISIONS)
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