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JUDITH T.TERRY �•�� �'�: Town Hall, 53095 Main Road
TOWN CLERK 3 CZ
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
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Southold,New York 11971
MARRIAGE OFFICER Fax Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER _�.( `�►a®.i.� Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,01./
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3522-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SPICIJARIC, JOHN
Mailing Address 1 P. O. BOX 108
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 995 GARDINERS LANE
Property Address 2
City St Zip SOUTHOLD • NY 11971-0000
Owner Telephone No. 516-765-3607
Tax Map No. section 70.00 block 8 lot 47.000
Cross Street PINE NECK ROAD
Issue Date: 10/08/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFQtf. ''-
Town of SoutholdCQG Application No. ,,3c.5-2.2.Judith T. Terry, Town Clerk �� ;,
Town Hall, 53095 Main Road ". $10.00 - Residential
P. O. Box 1179 tri • s ;' $25.00 — Non-Residential
Southold, New York 11971 �i : O ••`�
Telephone
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/0
DATE /O - - goo
OWNER NAME: Ohn /a/ AR/�
OWNER MAILING ADDRESS: p D,, "----&9,)e /De'
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OWNER PROPERTY ADDRESS:. q7 ,j L� 1�/c�� /4). ".t0 !.Sti_
� o11 � , 4). L/ 1/171
OWNER TELEPHONE NUMBER: 71)5 -,3b o7
TAX MAP NO. : Section / A�fpm -,Block r Lot
CROSS STREET: ,4)E
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential v" Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signatur ofIicant
RECEIVED BY:2
Tow Clerk's Office
DATE: RECEIVED •
- -
OCT 4 1996
Southold Town Clerk
,
+ SUFFOLK COUNTY DEPARTMENT OF HEALTH
, ' EASTERN 6ISTRICT H.D.Ref. No. ;
County Center, Riverhead, New York '
` PA 7-4700
APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
�\ Inspection for approval is requested, pertinent installation data herewith.
1-Name of Owner c10///t/ S`P./C/.Tf'R/ . 3-Subdiv.
Address X176-S'/1 SRr iayNJ fM'//2. o Phone2l2Wfc- 'd7„3 4-Section No.
\\ ,, 2-Name of Builder sf/mE Phone 5-Lot Number
1, Address 6-Bldg.Permit No.,z 9 1 Z
7-Sewage System installed by pp&gip ✓ 77 R Phone-,24e1,;
Address , A7C//,/TR4D Si,1 DAP/.�. 7, ,/ ' //9S:
ND 8-(a)Deed location of property c/S c/4ReNA/4 'S.(4 7/ann`O i/4ir/4f dk AYD,
(b)Hamlet or Village ..S'oGt Wakb (c)Town Soc/77V0Io
9-Septic tank-Gal _ L ft.W ft.Liquid Depth ft.
10-Cesspools-(a)No.pools 3 (b)Blocks` below inlet-1) 2) 3) - :
(c).Block`'size-L ' in.W ` in.H in. (d)Precast pool) (e)1X2 3 -`
(f)H ,qf ft. D in; Diem ft. •o in. (g)Finished grade to cover / ft.
(h)Backfill Material, 'b o4,W L .
11-Water Supply: Public System ; Private Well 'x
If Private, the following questions are to be answered:
12-Private Water Supply System installed by Phone
Address
13(a)-Total Depth of Well (b)Depth to Static Water Level
14-Diameter of well pipe in.
15-Name of Laboratory 16-Method of Disinfection
17-Date ready for inspection!/M .24/7/7 .
The undersigned CERTIFIES: Above systems have been constructed and are
in compliance,with the Suffolk County Health Department's current Standards, Bulletins
and Amendments thereto.
18-Date jl'J 2.5i/9d digned (9,,,,,,,,_ .,,..c_.,.,,..c_.,( er - alder
19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions.
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FOR HEALTH DEPARTMENT,USE ONLY �
Inspected by C Date / .5.) G•�
Based upon the inform tion stated above, satisfactory functioning of the
above systems can be expected with proper maintenance and Ve,eg
62.
Date '\pR 2 R 1970 Approved District
Engineer
S-5e
r "
4
Instructions for Submission of Installed Private Sewage Disposal and Water System Application
Applications are to be submitted in duplicate. Required information should be
typed or legibly printed in ink. Inspectors are not permitted to make inspections
of installations until applications have been submitted to and accepted by this de-
partment.
The item number on the application form and item number listed below are the
same:
1. Owner's name and address - if owner and builder.are same, so indicate.
2. Builder's-name and address - approvals 'will,'be mailed to this address.
3. Give -name of filed realty subdivision map.
4. Section number of realty subdivision map: ' -
5. Lot number -of plot on which disposal unit is constructed.
6. Building permit number assigned by the Building Department.
- --7.` -Name-"of--person: or-fi--rm,vhcrtactually--'const$'acted-the-=sewage-disposal -facilities.
8. (a) For example: s/s Jones St. , 100' 'e/o Smith St. (b) Hamlet, (unincorporated
area in township) , for example: East Moriches '' Village (incorporated area) ,
for example: Northport. • (c) Township,sfor example: Brookhaven, etc.
9. Give inside length and width in feet. Liquid depth is measured in feet from
bottom of outlet pipe to bottom of tank.
10. (a) State number of pools. (b) State number of blocks below inlet pipe for
each pool. (c) State length, width, and height of cesspool blocks in inches.
(d) Indicate by check if precast• sections are used. (e) Give number of leach-
ing sections per pool. (f) Give height and diameter of each leaching section.
(g) Give depth in feet from finished grade to cesspool cover. (h) Describe
backfill material used.
11. Indicate by check if water supply is public or private.
12. Name of person or firm who actually installed the water supply facilities.
13. (a) Give depth in feet from top of well pipe or casing to well point. (b)
Depth in feet from top of well pipe or casing to water level in well.
14. Inside diameter of well casing.
15. Name of laboratory performing the examinations.
16. Describe method of disinfection, for example: quart of laundry bleach in ten
gallons of water poured into well and allowed to stand six hours. '
17. State date on which installation will be ready for inspection.
18. Application must be signed by builder or owner. Signatures of subcontractor,
superinrendent„etc. , will not be accepted.
19. Indicate location of Water & Sewerage Facilities with accurate dimensions on
sketch.