HomeMy WebLinkAboutMoran (2) # c _
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w r;. Town Hall, 53095 Main Road
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P.O. Box 1179
Iii Southold, New York 11971
JUDITH T.TERRY ®� TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERIC
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 777-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner MORAN,ANITA
Mailing Address 1 P. O. BOX 26
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 105 SMITH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-5995
Tax Map No. section 98. 00 block 4 lot 1.001
Cross Street INDIAN NECK LANE
Date Of Last Pump Out 0/00/00
Issue Date: 8/03/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK Fair
77
Town of Southold S ' Application No. 7
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Roads ' Residential
to
P. O. Box 1179 =� �. �, Non-Residential
Southold, New York 11971 O ® efeh j
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Telephone ( �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 777
Fee $70
DATE 7/9'°1[fr
OWNER NAME: M U 2�N i NITA
OWNER MAILING ADDRESS: O /3. 2- ro
Pe c d /Ir/G 4- f/%crd
OWNER PROPERTY ADDRESS: /of Si?l7/f
Aco/v/r- /v/ /,IL ft
OWNER TELEPHONE NUMBER: 7.3V
TAX MAP NO. : Section 7 ( Block 174. Lot /- /
CROSS STREET: _ie-®V•(j/n/l/ C /C 4/t •
TYPE OF SYSTEM: Septic .Tank New Existing
Cesspool - New Existing —
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature o Applicant
RECEIVED BY1764c.,d ,•
ege bwn LQlerk's Office
DATE: AUG 03 'Meg
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' SUFFOLK COUNTY DEPARTMENT OF HEALTH
`t '- EASTERN DISTRICT H.D.Ref. No.
County Center, Riverhead, New York
PA 7-4700
APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
`0 Inspection for approval is requested, pertinent installation data herewith.
e
1-Name of Owner j'.}n.ch �-y, rr, ,�.,-,._.. 3-Subdiv. -
n)- Address Ps,,,,, ,_,' u )1, y-- Phone 4-Section No.
9. 2-Name of Builder { ;-r ., L_ <. ,(11; Phone
Address ( 5-Lot, Number i .,.. 2._-x- ,-_� .. 1 6-Bldg.Permit No. -Yc-�7_ Z
C!5; 7-Sewage System installed by rf,, Phone ? 3
Address ri `' ,y., ., f_ 3f./ . C /
.)
Q8-(a)Deed location of prop6rty -.;..•,.1{ ra..+ 1,,,�..F'.4 p f k t; _ k R.Jx.. 4--"w,-,-
(b)Hamlet or Village P C..c c..;;4:‘._ .; (c)Town ,_�- ',_if)
9-Septic tank-Gal L ft.W ft.Liquid Depth ft.'.; _
10-Cesspools-(a)No.pools 1,... (b)Blocks below inlet-1 2)143)'--"--- ---
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(c)Block size-L jl in.W Ss' in.H 3( in. (d)Precast pool (e)1 2 3
DI (f)H ft. in; Diam ft. in. (g)Finished grade to cover /'- ft.
• (h)Backfill Material ;., ,.a4 - ,,,..... i.„-e.-
11
,.z,. 1„r+'�,,-
N 11-Water Supply: Public System `1- '1 ; Private Well (1-4/L --
If Private, the following ques'tions'areto be answered:
12-Private Water Supply System installed by 1,1�e:.E'_'r`�„ii t,,, .3
Address \ --' L,_" • _ ;7 -- -- J
13(a)-Total Depth of Well r� (b)Depth to Static Water Level / 2 r
(�` 14-Diameter of well pipe in.
�! 15-Name of Laboratory ,.,.�, _ t,-, . ., 16-Method of Disinfection ('�t ,,-. , .- Ec
17-Date ready for inspection , �� �� . -
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`- ') t (1 Signed '
('' LL-.T k '
Qr - Builder
19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions.
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—'s /-41°WzA A
ii. ,
ST'EE
FOR HEALTH DEPARTMENT USE ONLY
Inspected by 'Ti).. ski' 7 Date /0-2-6 9 -
Based upon the information stated above, satisfactory functioning of the
above systems can be expected with proper maintenance and care. •
Date OCT 2 0 1g69 Approved ;, , ` t .r ;�:jq �,/y t'lj/7
D-1 s;,ric Pncine n '-'-.
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