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ELIZABETH A.NEVILLE 1 � y�\1 P.O. Box 1179
TOWN CLERK Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ; Fax(516) 765-6145
RECORDS MANAGEMENT OFFICER
MARRIAGE OFFICER N 1i Ol �00v) , Telephone (516) 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. 2168 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : FRANK RAYNOR
Address 1 : P.O. BOX 707
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
ADDITION OF CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM WELLS,
BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION INSPECTION
REQUIRED.
Name Of Owner RAYNOR, FRANK
Mailing Address 1 P.O. BOX 707
City St Zip MATTITUCK NY 11952
Property Address 1 3370 WICKHAM AVENUE
City St Zip MATTITUCK NY 11952
Tax Map No. section 107.00 block 9 lot 15.000
Cross Street CONKLIN STREET
Building Permit Number Cross Reference:
Issue Date: 10/25/99 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
Signatu
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Date
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ELIZABETH A. NEVILLE ` Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
y Z
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ; Fax (516) 765-6145
` hone (516) 765-1800
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RECORDS MANAGEMENT OFFICER SIJ O 1 Telephone
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FREEDOM OF INFORMATION OFFICER : ' '4.•11
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED: October 4, 1999
Transmitted herewith is a copy of application No. 2255 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Frank Raynor
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 this office.
Thank you.
Linda J. Cooper
* * * * * * * * * * * * *
I
have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE -
DISAPPROVE -
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
ii7gnatu
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Date
OFFICE OF THE TOWN CLERK , ••CAVU K .
TOWN OF SOUTHOLD �• � `QG= Application No. 2-2
ELIZABETH A.NEVILLE,TOWN CLERK
cf./
P.O.BOX 1179 _ Construction
SOUTHOLD,NEW YORK 11971
Alteration Q�
Telephone O,�,y �ir $10.00 -Residential
(516) 765-1801 = 41 ��' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ ^
DATE /0 /
APPLICANT NAME: 414,i1'
APPLICANT ADDRESS: .7,Y7 a L• lc- ��,., If-
/19
9--
/19,9-x/!v�/� ' �i Pf``z
SEPTIC CESSPOOL
DESC TION��OF PROPOSED CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: A;;;>9?-e---3e.
4-fes ,2, ,-"Z"
OWNER MAILING ADDRESS: C
/)74 i l�L�- �y� //y r L
OWNER PROPERTY ADDRESS: ,37J c:) w'rcL�j sZ „5=4„:5
TELEPHONE NUMBER OF CONTACT PERSON: 077.E
TAX MAP NO. : Section /C2 Block 9 Lot -'J
CROSS STREET: Cr) -' S 2'
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature f Applic
RECEIVED BY :
To Clgr�If's Office
DATE: /6/ 7/ /�}
SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Refarence No-
EASTERN DISTRICT, RIVERHEAD,N.Y.
APPLICATIONto said systems is requested,pertinent dataherewith:
FOR APPROVAL
CT PRIVATE SEWAGE DISPOSAL SYSTEMS ate
Approvallo construct
1-A pl icPhone 29& ?t •-Sub div
abnt �'tit�k tiltytlOY' 7-Section
Address /d ip1),0a A vs listtitiwic, K_Y. -Lot No.
2-Detailed property locatfon
�t { ck 9-Private well? yoe
Hamlet t ° --a'�' dsta~nce�t° nearest main
3-Public water supply name
4-Lot Size: Width_11.141ft. Length, wit) ft. (also enter on center plot plan below:)
5-Dwelling: Single Family ix/ Two Family? L./Cellar? Lf Slab? LiCrawl Space? Li
10-Proposed system: Septic tank LJPrecast Cesspools UShallow pools L_./Other L,./
11-Septic tank inside dimensions: Volume alls.Length ft. Width ft. Liquid. depth ft.
12-Precast sections: Number Square Ft. Cesspools. L: Block sizeincs.Dins.H ins.
Total blocks below inl t: #1 #3•
PLOT PLAN
Tank Capacity"LGals.
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PUMP G.PQM._____-___
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The Undersigned CERTIFIES: "Construction of authorized installations will be in
accordance with the Suffolk County Health Departments' current Standards, Bulletins,
and amendments thereto, covering Private Sewage Disposal Systems".
Date W.)-61.1%, Signed � ,e ^/
OWnor or� Bu e�
FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the
opinion of the Health Department, that an adequate and satisfactory Sewage Disposal System
can be installed on this Plot.
Date Signed'74' fw—lviiig"
(10/65 Revis.)
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