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ELIZABETH A.NEVILLE 1.� Town Hall, 53095 Main Road
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TOWN CLERK P.O. Box 1179
ti = Southold, New York 11971
REGISTRAR OF VITAL STATISTICS O Fax (516) 765-6145
MARRIAGE OFFICER `
RECORDS MANAGEMENT OFFICER V49 aOwTelephone (516) 765-1800
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FREEDOM OF INFORMATION OFFICER 'W '���1.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2118 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : KELLY DAVIS
Address 1 : 9 OAKWOOD STREET
City St Zip LAKE RONKONKOMA NY 11779
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 #R10-96-0042
Name Of Owner DAVID, KELLY
Mailing Address 1 9 OAKWOOD STREET
City St Zip LAKE RONKONKOMA NY 11779
Property Address 1 970 PINE TREE ROAD
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 104.00 block 2 lot 1 .000
Cross Street HORTON ROAD
Building Permit Number Cross Reference:
Issue Date: 7/28/99 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
illik., i tcK
ELIZABETH A.NEVILLE t �`Z� �t; Town Hall, 53095 Main Road
TOWN CLERK Cl) - , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS l) rft t Southold, New York 11971
MARRIAGE OFFICER : O # Fax(516) 765-6145
RECORDS MANAGEMENT OFFICER ` 42, 4. 00 Telephone (516) 765 1800
FREEDOM OF INFORMATION OFFICER Wil' '�Op-
9 9
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: July 12, 1999
Transmitted herewith is a copy of application No. 2206 for a Cesspool/
Septic Tank Construction Permit submitted by:
Kelly Davis •
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
DISAPPROVE
Comments:
ignatu
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1 4 / `1 1
Dated
1, ,,,,,,,,,
OFFICE OF THE TOWN CLERK `` llik '
TOWN OF SOUTHOLD � 0� CSG= Application No. oa-Q(„
ELIZABETH A.NEVILLE,TOWN CLERK ,�,
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971 T Alteration
�y0 ���•' $10.00 - Residential,-
(516) 765-1801! 1 ,,,�' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
RFCFP'Frn for
JUL 1 2 1999 CONSTRUCTION or ALTERATION PERMIT
(own Cleric Southold SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE ,9t.2- Y �Sq
f
APPLICANT NAME:
APPLICANT ADDRESS: l �CO
SEPTIC \ CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
JLA A') h,et U-saCZ--
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: \Z-e.`, (\)A\1:k
OWNER MAILING ADDRESS: 'k C^aa y.,.. ccs) 5-c
OWNER PROPERTY ADDRESS: --' _ - - _ 11"-' 9 0
TELEPHONE NUMBER OF CONTACT PERSON: ��o -1
TAX MAP NO. : Section 01.60 Block 02 .00 Lot Ons I . C�v
CROSS STREET: 4e; n -- H0 #4"t"-SP-CO
BUILDING PERMIT NUMBER CROSS REFERENCE:
ignat - .f Applicant
0 r
RECEIVED BY: r�
own Clerk's Office
DATE: '7 a` `�
CP • f M
j
PeA. Dir k,•'tk✓� 6� /o v2 r ` r,,'
' SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES , 9. O ~
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PERMIT FOR APPROVAL OF CONSTRUCTION FOR A ;c
DINGLE FAMILY RESIDENCE ONLY
DATE 6_1,4_,76 ND 12.t0-6-i&-c50,-1 ..
APPROVED
IMPROVED
FOR MAXIMUM OF 4
E PARES THREE YEARS FROM DATE OF APPROVAL
S.C.D.H.S. ENDORSEMENTS PINE TREE ROAD
(ASPHALT SURFACE) e 1034
9.93
PLEASE NOTE 1
'79..7172
EDGE o/PAvtwc_Hr 10.19
Sanitary system is not to be N63'13'S0 LQQ�_IL4 POLE-
placed under driveway area. a -- B9 IRON PIPE
76.5 . PROPOSED WELL. 0.7'S.
-- MAINTAIN 750'MLN. ON LINE E/W
SEPARATION FROM J
EXISTING&PROP.
0 SANITARY SYSTEMS j 0
W
U
P W
N I L07 59 I �� DELI
h
Is
DARK BROWN LI C3 It '
1, SANDY LOAM WELL 41 N
BROWN LOAMYO
—2.5" CLAYEY SAND O I I N P
BROWN Iz LO` 59
CLAY SAND
—4' ••NC)h
ryOla. O
PALE BROWN QQ
IMP4s•
FINE 70 RCP
COARSE SAND ROVED Z I I Pz,,
—17' O P�0 6'f W. I O
TEST HOLE ICT FR �5 O
O \O
WELL57' • VACANT
Z NI
AREA: 10,275 Sq.Ft.
Z0.465 A . In
IMPROVED
19.7 0_I 'P- 7 1000 GALLON '
WELL AS SHOWN IRON NIR 10.+ LL.7 - SEPTIC TXNK.
6.6'S. ✓/0 LC'I 57 0.I'W LI)6'I X 11'DEEP
SANITARY UNKNOWN +.6'w 1C IP— LEACHING POOL.
O S66'22'50"W 100.00' ERXPAMNSION.sox
P/O LOT 5
IMPROVED
O.,
w
\;--). WELL
CERTIFIED TO VEY OF
KELLY DAVISI PART OF LOTS 57, 57 & 59
COMMONWEALTH LAND TITLE INSURANCE
COMPANY (TITLE # 70990803) MAP OF