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HomeMy WebLinkAboutBergen, Bruce o,o��gtfFOi,�C ELIZABETH A. NEVILLE i���• ' %; Town Hall, 53095 Main Road TOWN CLERK o P.O. Box 1179 t ti Z v, Southold, New York 11971 REGISTRAR OF VITAL STATISTICS Q �� Fax (631) 765-6145 MARRIAGE OFFICER � y� �� RECORDS MANAGEMENT OFFICER �_��l .0s-� Telephone (631) 765 1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT CONSTRUCTION OR ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. 2328 R Residential X Non-Residential Fee $ 10.00 Septic X Cesspool PERMIT ISSUED TO: Name : BRUCE D BERGEN Address 1 : 19105 MAIN ROAD City St Zip MATTITUCK NY 11952 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 #R10-00-0080 Name Of Owner BERGEN, BRUCE E LEIGH ANN Mailing Address 1 PO BOX 1198 City St Zip MATTITUCK NY 11952 Property Address 1 3965 GRAND AVENUE City St Zip MATTITUCK NY 11952 Tax Map No. section 107.00 block 1 lot 2.006 Cross Street REEVE ROAD Building Permit Number Cross Reference: Issue Date: 5/24/00 Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) ,11 =�FFO� .. C�~ ELIZABETH A. NEVILLE t 11 y�: Town Hall, 53095 Main Road TOWN CLERK % o % P.O. Box 1179 CA REGISTRAR OF VITAL STATISTICS v' t� Southold, New York 11971 MARRIAGE OFFICER :O 1i N. el Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER 701 �•V�le Telephone (631) 765-1800 FREEDOM OF •.-i ..•tom f N OFFICER ��� • 1 1 6 V, 70001 , OFFICE OF THE TOWN CLERK L— _3 TOWN OF SOUTHOLD TO: inuthold Town Building Department FROM: Linda J. Cooper, Southold Town Clerk's Office DATED: May 22, 2000 Transmitted herewith is a copy of application No. 2416 for a Cesspool/ Septic Tank Construction Permit submitted by: Bruce D. Bergen 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. Thank you. Linda J. Cooper * * * * * * * * * * * * I have reviewed the application and location map of the project cited above and make the following recommendations: APPROVE V DISAPPROVE Comments: tur>S(4"'"'"*" ---. _ Dated OFFICE OF THE TOWN CLERK ,"' .,A��0L TOWN OF SOJTHOLD ,�' `Q Application No. ELIZABETH A.NEVILLE,TOWN CLERK P.O.BOX 1179 .04; Construction k SOUTHOLD,NEW YORK 11971 FA V, Alteration Tele hone Q $10.00 - Residential p (516) 765-1801 _ �l �1��'� $25.00 -Non-Residential TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICAT ION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. Fee $ DATE J � ` 7/67. APPLICANT NAME: Z3,evct APPLICANT ADDRESS: 9 /o,j— /!7,¢r.t.1 Zir,/s7.0 /?g 7Zrvc/< //y ././5 SEPTIC CESSPOOL / DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: OWNER OF PROPERTY: /3,<,vCf ,9 /jk,¢GcAJ > 21..z-67/ OWNER MAILING ADDRESS: //ir OWNER PROPERTY ADDRESS: 37‘3"-- C/z, i-, /9./ i rZVV x-77 t"c/c /I/�f /T-52,04'//7r2.. yzgp -z62.7 /71 TELEPHONE NUMBER OF CONTACT PERSON: 4/7z- oou✓ TAX MAP NO. : Section /o7,coo Block o /. oo Lot oo z - o 0 6 CROSS STREET: fvF- BUILDING PERMIT NUMBER CROSS REFERENCE: Signature of A=nt RECEIVED BY: /V AL---s-14-10 Town Clerk's Office DATE: /J" id. i.----..o,s_.,`-r.__.,r=e.o` c.xESEo.---rE r,.iltc rJ-r 1 �f.rr'd' Com' �.�CdrT—T i T`.1G1rL G smau uG C'3'T,OTS ,---_J 2•:= — t 8. ." I r ,.o . (1',� �•L.80: f•—••••=2•1=1.'L..3J 1t�L--••••...j.•! J'ZJ�- / 8I*EOTTOcONVENAfiTBd•RFSTRIG S 44 Z �� 4 /QP° c..-r- r-%^---r--rtT.J,GtG T=ay.Jt•-J r..- • o..1rh_.lo1..r1=, SUFFOLK COUNTY DEPARTMENT OF HEALTH S6iVltB (� ' ,.—J=Go i--.1.i--.1.G— C�f . —..-1:—/. PERMIT FOR APPROVAL OF CONSTRUCTION FOR A yU, SINGLE FAMILY RESIDENCE ONLY l/1 o f ooc .— 10— — c=6 1 ,— 2.G KrE MAY 0 9 2000 HSREF.No. R/0—oo —©a13 �/'0 u �PROvED ��""" 5� ¢ m , �V I naothoried alteration or addition to this run ry is a.Wawa of sectio,7204 of the f / New bosh State Education law. FOR MAXIMUM OF BOOMS / Copies of this son et map not bearing the land Samosas inked or embossed seal is /' not considered to bra true valid cops. EXPIRES THREE YEARS FROM DATE OF APPROVAL JJDistances shoos from property lines to existing straetnrrs are fora specific purpose and use and are not intended to guide in the erection o(k.ees or otters res. { \ -- --- prepared sen non his hereon shah ran nnl.to the lrrrean fns hernia the sun to th is \\\`� p epared and on his behalf,to the Comm.!.or tge.eies iMed and to the , ,•� 5i // assignees of the kodi,g lastitation.(ertifteatioas are not tcaasfer.ble to additional O1 _ �_ �4 R' institutions tutions or subsequent owners. I. X4'3'. ./ q3.o' / 10 / 'V h-, I PS2t7F09E,D 1 Ir • J AO\' ! L STY11 --__ -r. TEST NQL_� __ EL; 'I33 ll1 \\\\ 'm Res. I d. � 2If •rDral.lM._S1LT1_ L9 x'1''12.3 1 FF GS.o) Q P/'5 Sit-T1 --i3uu__LSj 171 Q PALE 13ROLJ J riNt,0 zp/ . '. _• ,4_.5) ITO MEDIUM SANG i• .' 1 if) i .. \ru S�' 1, ���rd0 1 U,, ir:„;... __ / 1r \� �t 1.':14 ,-'3.2_ 111 -4 0.l 4 2•. •.• I r ) S•" v__! `\ 24t.CoZi' �\ Co...--1•••=.4=2.Tot e3� xT-F vas ,=•c...— ..._• I j' \\ x. SEPTIC E, WELL �QC5 PE2. �( S\ tJE1Gti6oi-2S 4 oL0 — ,.../12,4 -4..5 i ' zz o A-. ACn�W • - a-3.s •I . -\• `0 Is,� mac ?•-- t i_ -I � AI, • r \‘ .i , - "� L__...=......_.r=, ..�I= � ./or—lC , ,- sj i :oZ,.......•.•..11r-, rT. (07.-" I 'U -�. C1"p..pt 1��'!Q1 4=r —. AMEMD. 2...Co I