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SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 4085 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : DAVID & SONDRA RUSSELL
Address 1: 1375 SMITH DRIVE SOUTH
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner DAVID & SONDRA RUSSELL
Mailing Address 1 1375 SMITH DRIVE SOUTH
City St Zip SOUTHOLD NY 11971
Property Address 1 1375 SMITH DRIVE SOUTH
City St Zip SOUTHOLD NY 11971
Tax Map No. section 76.00 block 2 lot 35.000
Cross Street MAIN BAYVIEW
Building Permit Number Cross Reference:
Issue Date: 11/01/12 Elizabeth A. Neville
Southold Town Clerk
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ELIZABETH A.NEVILLE,MMC ��� Gy 3 Town Hall,53095 Main Road
TOWN CLERK p P.O. Box 1179
CI, Z Southold,New York 11971
REGISTRAR OF VITAL STATISTICS : `y
O Fax(631)765-6145
MARRIAGE OFFICER y ��
RECORDS OF MANAGEMENT OFFICER :��,( L •#`�; ��� Telephone(631)thfork 765-1800
FREEDOM OF INFORMATION OFFICER ��' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK E r
TOWN OF SOUTHOLD
_ MAY - 9 2012 ,L;^)
TO: Southold Town Building Department
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FROM: Carol Hydell, Southold Town Clerk's Office TO""`1 D
DATED: May 9, 2012
Transmitted herewith is a copy of application No. 4085 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
David & Sondra Russell
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.
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Maintain required setbacks from adjacent wells, buildings, property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
Signature
/72--
Dated
. o "
ELIZABETH A. NEVILLE kit a
i q`t` -Fv
r - .. Town Hall,58096 Main Roa.
TOWN CLERK 1 i • P.O. Box 1179
• REGISTRAR OF VITAL STATISTICS i
.
MARRIAGE OFFICER 1i Southold, New York 11971
AW Fax(681) 765-6145
1
RECORDS MANAGEMENT OFFICER
VfQ1O�iil Telephone(631)766-1800
FREEDOM OF INFORMATION OFFICER *
---..„„..011 soff southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT '
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
i.isi 6Z
Residential @$10 y or Non-Residential @$25 _ Application No. 'I O V
i + Permit No.
Applicant Name L1vvb "r S UNJb�f RtSCCu-_
Applicant Mailing Address \ 3 -7 5 SM j--TN b R .,
c OUT- HID l. b , NA \ \9,--1 \
Septic Tank or Cesspool X
Brief Description of Proposed Construction or Alteration I`nn
as i n3 ' vi r C�
Location of Proposed Construction/Alteration: RuOwner of Property: SODR I\ RT)P0 It) S S L L
Owner Mailing Address: \ r- el 5 Sr" T_ b St,
OtAT\-tOL-b , Qul Mil
Owner Property Address: 1 --7 S S N\ T:1-1b R &,
Name and phone number of contact person SO Nb - C o3 l) 901 a\aNs
Tax Map No: Section 1 tQ Block a Lot 44iiiik SS
Cross Street Rf\i_Ni lbim l
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SITTEY WITH HETH DEPART NT APPROVAL
Al-O\A eke,- r 59 ios
Signature of Applicant Date
Received by:
1'
N
,I SURVEY OF PROPERTY
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1 LOT 107 A T BA YVIEW
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TOWN OF SOUTHOLD
67.00 26�" SUFFOLK COUNTY; N. Y. ,
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STEWART TITLE INSURANCE COMPANY
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LOT NUMBERS REFER TO "MAP OF GOOSE NECK" �� a'V 0.� ; -
FILED IN THE SUFFOLK COUNTY CLERK'S OFFICELAND s
ON NOVEMBER 22 1948 AS FILE NO. 1663. /�.' .Y.S. LIC. NO. 49618
ANY ALTERATION OR ADD/770N TO THIS SURVEY/S A V1OLA770N 'ECONIC YORS, P.C.
OF SECTION 72090E THE NEW YORK STATE EDUCATION LAW. (631) 765-5020 FAX (631) 765-1797
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CER77FICATIONS P.O. BOX 909 ,'
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF
AREA=6 70O SO SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET
e =PIPE WHOSE SIGNATURE APPEARS HEREON.
SOUTHOLD, N. Y. 11971