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ELIZABETH A.NEVILLE,MMC �� i:: � �� Town Hall,53095 Main Road
TOWN CLERK � ���t ='=�fi P.O.Box 1179
�s Southold,New York 11971
REGISTRAR OF VITAL STATISTICS t5 w Fax(631)765-6145
MARRIAGE OFFICER ��� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER �mj www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
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FROM: Carol Hydell, Southold Town Clerk's Office
MAY 10 2016
DATED: May 9, 2016 .— J. "";, _,DEPT.
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WJUzDn-,D- - OLD
RE: Cesspool Construction Application TOWN Off'S® OLD
Transmitted herewith is a copy of application No. 4386 for a Cesspool/Septic Tank Construction
Permit submitted by:
Joachim & Judith Yohalom
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.
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
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Signature
Dated
SCxJTHCLD VlASTEVIATER DI SPCRAL PERM T
OCNSTR JCTI CTI CR ALTERATI OV PERM T
SEPTI C TANK or CFSSPOCL
Per rri t W. 4386 R Resi dent i al X I bn-Resi dent i al
Fee $ 10. 00 Sept i c X Cesspool
PERM T I SSUED TO
%rre : J CAC H M & J LAI TH YC HALC M
Address 1: CJ O PAT NUCFE
City St Zip SC LJfHCLD W 11971
Descr i pt on of Pr oposed Const r uct i on or AI t er at i on
SAN TAR( SYSTEM FCR SI N 3-E FAM LY Dd'EL.LI NG
APPROJED AS SUBM TTED AND AS APPROJED BY THE SLFFC LK OCtJNTY DEPARTMENT
CF HEALTH SERM CFS. FI NAL APPROVAL RECD RED FRC M THE SLIFFC LK (xtJnl N
HEALTH DEPARTMENT. REF #R10- 16-0030
Narre Cf Gruner JCAC H M & J LO TH YC F14LCAA
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N5iIing Address 1 GO PAT MSE
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51020 NN N RO D
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City
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City St Zip SCx1THCLD N( 11971
-------------------- -- ----------
Pr oper t y Address 1 965 EDJARDS LANE
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CS t y St Zip CRI ENT W 11957
-------------------- -- ----------
Tax Nl�p Iib. sect i on 18. 00 block ock 3 1 of 20. 000
------ --- ------
Cross oss St r eet EDIARDS LANE
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Bui I di ng Per M t Nunber Or oss Ref er ence:
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I ssue Dat e: 6/07/ 16 B i zabet h A Nevi I I e
-------- Sout hold Town d erk
JOIN SEAL)
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ELIZABETH A. NEVILLE a� �� Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS eY �
MARRIAGE OFFICER ® ® Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ��®� ��®� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER 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.
Permit No.
Applicant Name fX� Chc X,61 /6/71
Applicant Mailing Address 0/0 �G� l Dfa/v'
67 0 29 Ma /Pi- .gtga% S��o to //'7 Z/
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:��ati-f
Owner Mailing Address:
Owner Property Address: 7(O 4 G(&2 4ZA Za.4z.?
Name and phone number of contact person &74- t&Dl4e 0
Tax Map No: �r Section / 9 Block U 3 Lot Z�
Cross Street :FW60 'p (i?71 (":] sic
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY IFH TH DEPARTMENT APPROVAL
Signature of Applicant Date
Received by:
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PROPOSED SEPTIC SYSTEM /
(6 BED ROOM)
1-1500 GAL. SEPTIC TANK 8'0 5' LIQUID DEPTH
1-L.P. 80 X 16' DEEP WITH SAND COLLAR IO
3' ABOVE GROUND WATER
RAIN RUNOFF CONTAINMENT
HOUSE WITH AUX. STRUCTURE '-'-----'--
3837 sq.ft.
3837 x 1 x 0.17 = 652 cu.f.t
652/42.2 = 16 VF o .
PROVIDE [4] DWS 80 x 4' DEEP
DRIVEWAY 561 cu.ft.
561/42.2 = 13 VF
PROVIDE [2] DWs 8' DEEP
OR EQUAL
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32 a65kg 9
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
'llvalbn In, PEOMIT FOR APPROVAL. OF C®NSThUCTiON AOR A
�+'f tfion egUi ed -9INGLE FAP14(
For Sani [:Y RESIDL:I�tCI ONLY
� ate
By He1th Department DATES . REF.'No. 3�.
APPROVED
_ . FOR MA, j 69
EXPIRES TNR - YCpRS FROM DATE OF APPROVAL
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