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ELIZABETH A. NEVILLE t��� • Town Hall, 53095 Main Road
TOWN CLERK O - P.O. Box 1179
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Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ; •F �� Fax (631) 765-6145
MARRIAGE OFFICER y 9t
RECORDS MANAGEMENT OFFICER �__�O! �a0 i' Telephone (631) 765 1800
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2321 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : NORTH FORK MANAGEMENT
Address 1 : PO BOX 696
City St Zip AQUEBOGUE NY 11931
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 #R10-00-0095
Name Of Owner DICKOFF, RAYMOND
Mailing Address 1 PO BOX 696
City St Zip AQUEBOGUE NY 11931
Property Address 1 RYDER FARM LANE
City St Zip LAUREL NY 11948
Tax Map No. section 15.00 block 4 lot 6.000
Cross Street UHL STREET
Building Permit Number Cross Reference:
Issue Date: 5/22/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. L \ 46 2 A� y� Town Hall, 53095 Main Road
TOWN CL 4 x ` , P.O. Box 1179
f w H $ Southold, New York 11971
REGISTRAR OF VITAL', TA BY ^-, �;l-;* �t
`F Fax (631) 765-6145
MARRIAGE OF CER f� ,,,,uY" L if,
RECORDS MANAGEME T • - ~ R --mi �a� ��
- i� Telephone (631) 765-1800
FREEDOM OF INFORMAT ON OFFICER ,,,,���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: May 17, 2000
Transmitted herewith is a copy of application No. 2409 for a Cesspool/Septic Tank Construction
Permit submitted by:
North Fork Management
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE %..../
DISAPPROVE
Comments:
Signature
S(A-AA--c- ------
51talb0
Dated
OFFICE OF THE"TOWN CLERK ,t'�CJ�l l _ IOU(
TOWN OF SOUTHOLD i6'' "Q Application No.
ELIZABETH A.NEVILLE,TOWN CLERK
PO.BOX 1179 . Construction
SOUTHOLD,NEW YORK 11971
o � ; Alteration
to �
Telephone AQei $10.00 - Residential
(51 6) 765-1801 l �, $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVED
APPLICATION
for MAY 1 7 2000
CONSTRUCTION or ALTERATION PERMIT
Southhold Town Clerk
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE 51/7/6°
APPLICANT NAME: /1.)0/C 7-# fOf, ' /4,110416. h1 N/
APPLICANT ADDRESS: / o i3oX
Q cif i ee./4 ic/ ' • /773/
SEPTIC CESSPOOL U
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LZ.1 s/,��2 14,x,// /9we2/,,-� —
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
OWNER MAILING ADDRESS: /p ,eoX YC
/962r./F/3a'u£ N/ // 1/
OWNER PROPERTY ADDRESS: c4-k2/¢ 1,44.24-__
)09cPcr£13op'C5 /f er,/,/ 7/13/
TELEPHONE NUMBER OF CONTACT PERSON: 7 q2-3 5'O
TAX MAP NO. : Section /5— Block 0 "-/ Lot O
CROSS STREET: t/f-f_ Sf
BUILDING PERMIT NUMBER CROSS REFERENCE:
Sign of Applicant
RECEIVED BY :
Town Clerk's Office
DATE:
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(vacant) CVacant) TOWN OF SOUTHOLD
150,00' SUFFOLK COUNTY, NEW YORK
l'
n=za.�N 88'26'00' E n•zo.e�
<u<r a=zae'•
;�. 1000-15-04-06
SCALE: 1"=30'
Z APRIL 12, 2000
•
c LOT 59 0, r�
g Ct�0 UHL LANE
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+ PLEASE NOTE
Minimum distance between well
f*,. arv.wa• and cesspool is to be 150 feet.
ci o c 9 PI
e t -- I
< I SUFFOLK COUNTY DEPARTMENT OFHEALTH SERVICES
o p prop.
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a,�., '� /Ise W ,� TERMH'FOR AFPID'VALOP 51'AUCITONF�A
y= c a SINGLE FAMILY RESIDENCE ONLY
30 likes/1 • DATE 5-2-00 �gRHCF.NyO�.,(t(K�{ .0O9
O SB _AZA4
co E APPROVED LL
/� 116
• c (vacant) FOR MA EMMA EXPIRE THREE YEARS PROM DATE OF APPROVAL
`a v 1bli
0
0 FOR SANITARY SYSTEM •
0.4m' a.m. BY HEALTH DEPARTAIENT
OW.' S 88'26'00' W 150.00'
LOT 60\
(dwelling)
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\So
g
VIE
1 $
PARIC \
NUMBERS REFER TO 'MAP OF ORIENT BY —
• SEA, SECTION TWO' FILED IN THE SUFFOLK well
NTY CLERK'S OFFICE ON OCT. 26, 1967 AS v
NO. 3444. -'
I am familiar with the STANDARDS FOR APPROVAL --
AND CONSTRUCTION OF SUBSURFACE SEWAGE ,`'�E�t yrOy.
?E4=21,000 S.F. DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES / o
and will abide by the conditions set Forth therein and
on the permit to construct. / ( '.Y.S. L I. NiFi -'
,-I C.P.
i aS
=MONUMENT ANY ALTERATION 9R ADDITION TO THIS SURVEY IS VIOLATION -,F.;• CONIC S • ORS,
THENEVT.
OF SECTION 7209 OF THE NYORK STATE EDUCATION LAV. (631) 765 5020 F- f• 2 7¢r .�
location of welts and cesspools shown hereon are EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS . P. 0. BOX 909 two
Field observations and or data obtained From others. HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF 1230 TRAVELER STREET
SAID MAP OR COpirS BEAR THE IMPRESSED SEAL OF THE SURVEYOR I .-167
ations are referenced to an assumed datum. WHOSE SIGNATOR APPEARS HEREON. SOUTHOLD, N.Y. 11971
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