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JUDITH T. TERRY i Town Hall, 53095 Main Road
TOWN CLERK � P.O. Box 1179
'' Southold, New York 11971
REGISTRAR OF VITAL STATISTICSs
MARRIAGE OFFICER ®a� �, Fax (516) 765-1823��® � AS Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 664 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ROBERT H. PETTIT
Address 1 : P. O. BOX 78
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSTEM.,
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH 'SERVICES ON 10/24/90.
Name Of Owner PETTIT, ROBERT H.
Mailing Address 1 P. O. BOX 78
City St Zip SOUTHOLD NY 11971
Property Address 1 515 MAPLE LANE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 100.00 block 3 lot 25.000
Cross Street SOUTHERN CROSS ROAD
Building Permit Number Cross Reference:
Issue Date: 11/27/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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' UA u' '�' Town Hall, 53095 Main Road
�' �� P.O. Box 1179
��1 �• Southold, New York 11971
JUDITH T.TERRY -�, �,��� TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERKIg7
TOWN OF SOUTHOLD gig
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To: Southold Town Code Enforcement Officer � `
From: Linda Cooper, Southold Town Clerk's Office N �• a
..x,,�.�'�.7E�
Dated: November 20, 1990 `°"' � -
Transmitted herewith is a copy of application No. 680 for a Cesspool/
Septic Tank Construction Permit submitted by:
Robert H. Pettit
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: q� i,,,,L-e o jt.� c - I �e (1 a QVU . Z-Wt-
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Signature
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Dated
-
OFFICE OF THE TOWN CLERKS -46/1 `,
Town of Southold sJ��=�{.:"''
- Application No. �o �0
Judith T. Terry, Town Clerk :,•�..,�.
Town Hall, 53095 Main Road o � .? . Construction
P. O. Box 1179 �y
Southold, New York 11971 O.'� r Alteration
Telephone °1xli[ � Residential
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. (0 *----0
Fee $ /6
DATE 1,4-0-ed,4 20) /15 a
APPLICANT NAME: Rd.ggie! t'( . /Q77 ( r
APPLICANT ADDRESS: � Peavii-Ei Pto'
e_ot dau /J r
SEPTIC ZC CESSPOOL rt-
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
C PPSV.Vu SF4776. Ucc A-DO e-,4- :cant_ i oc.,, i) /062
AAPpl Rt> P/A-V 90 So J.7
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Raga g, 7` l t(
OWNER MAILING ADDRESS: fQ -g
OWNER PROPERTY ADDRESS: gt ' /I-( GAIU6g._
TELEPHONE NUMBER OF CONTACT PERSON: •76C---zY 6-(
TAX MAP NO. : Section (CI� Block ) Lot 2.- 5
CROSS STREET: 50t)71-&20 C/?aSs /fib
BUILDING PERMIT NUMBER CROSS REFERENCE:- )9/..W-/e0
4/ 6-a/ -
Signature of Applicant
RECEIVED BY: /, /yet
Town Clerk's Office
DATE: d/I9d
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+ i _JI _ SUFFOLK CO.HEALTH DEPT.APPROVAL
CE95PGOL ?S I-� LLL- '; �' � — ,� ^ $� •
r7. '?CIS J •
3� ( --\ v-� WELL± )tda Fs 1 H S. NO. �L/' ]O- .la'
N, ,I u r_aS'—,r D i NIP I -`� ) ,/UN 2g ,..roved in accordance with Board of Review •
+ • ol = 'J 5p s r1._ nstion ted OCTCE53POOL' I '-',1----. .. ..
140 AO I O �; :; -. ivi., �•� 2r-.) I'�..T..`� __ . ...., ,.
V ¢ 1g ^terms da 24 X90'
cisspooL
• =5 �� z -TOW L. ! N�� ;2 ' �. �' j 1-iro--f 125'1.5- J. I ,t ' ��' 'P r i' • NFjt)!-a, OF .3
l- t ! 17-'J ` I ''�7 STATEMENT OF INTENT '
0 c� t `Q� �•` i — `' ; ;\f'��r �` �t;(tel ` vitt, THE WATER SUPPLY AND SEWAGE DISPOSAL k
In 44' (7 rh'
N. w ry _.-- --�'-- _ SYSTEMS FOR THIS RESIDENCE WILL'
I,., ti) C' L/ "-OF.SE'fC B� _,j 5 Q x y `^}I~' r- t j I) i f r CONFORM TO THE STANDARDS OF• THE
O ric.' , r �; i 1 t I I
(� �� {) ' \ _-to j4$'+f tt3�ss0 I_ 1 -, _ i r i # SUFFOLK CO DEPT. OF HEALTH SERVICES. •;
J1 al -I_ , S 11. +
I EN-CONSULTANTS
----_-`�__r]W __�._\ •y_ - - - —_ 'a/ELLi � _I S) APPLICANT 1329 NORTH SEA,RD, •• -
i'2Gi t-ir,i los& —'O r" i' '_;• I I, tOUTNAMPTON N.Y. 11969
I. - —2 I I' l SUFFOLK COUNTY F
I - W Sgg-3-63g0 HEALTH ,
- �- �`7 �f� f' t .r`V!:'. C,I% 1.7-':-.;,..r,-1(1.--':: '� . SERVICES - FOR APPROVAL 'OF-_
i I L l7 _ - — ------ CONSTRUCTI Y
_j _ TEST HOLE -� F ----- ---- DATE (���jJ� 19 19 �
CJ 0 `i CVAC, T) L'' tft
U�qO U �3
13
CS - - c.1. L j H S.REF.NO.. ' -
0.140+ Ven
cam- r r20r. — —L 12J E i,) 1.J• APPROVED. - C��r"rte n 1 'z
11. ¢ ,ii
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—__ __ j' _l ` ! -J 7 T f 'i BOAQO T=ETtGE IO5 5. 11'7, - Cl '`1 CE55PC3L�` ..:v
�- iJl i / Ut / SUFFOLK CO-TAX MAP DESIGNATION:
1- , i� I y,1. J ---- ;psi �� DIST. SECT BLOCK , PCL.
I \ (11 W 673 ;is/ELL+
!' - '� , , /I:
OWNERS ADDRESS:I Lh:):,�I_ I .WELL* C� \ '`i {?Q BOx _'� ` `i''c':`~"�";: vII r 1 5 > ?o: , =0UTHOLDNY. I1C�74�� 5v^ ! —J ,,/ 2s z �\
\ 76S_2866 ,(� I Q - =moo /, n DEED. L.F.,646 P.196 (QEF)
�ESSP��L± p WELLS //� CsFOOL+ TEST HOLE STAMP
O--%CES,'.'OOL ± , / t'ra•::.a-r_rH ye/Nation or aarlaon _
_-__ _ _------------------
-__—___.--_—_-____—� // M ih•s su�•ey Is a woinbon of
Sertwn'fro of the New York State
i d
PARK BRC4ht uao'n rLw
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'J �L _ ; 5NC(LOAM tilt"la° s•Ir.oroor',aria Coal a •/ a'-
toetonon o:ee considered AREA' T500 5.F e',ele Ir.Co„ 1.iJrr-; rnQ rUA`,
5<
/ Q.M tv[.)N E NT Br2CYv/N Guaronre-as mdird,, hereon shall run•
_...—. LJAMV SANDonly m the r'•1son ler whim I'',0 rurvel 'y
3 It prepare.,art on fee behalf to the ' 'r
-
• title ccmoaur,go:•ernmonnl agency and • k
____--_ I ` - lending Ins+lrcucn Irs•cd harcon and 5
AMENDED MAY 21 1990 to the:-..e,-e;i ++es d the lending Insti-
—_� I lotion GLarentses ire not transferable aJUNE 251 I cep to odd/tonal Instal/eons or subs sau.nt ,-•'4.kowners , r
PALE MOWN
MCCIUM 1V
COARSE SANG S ' -"
�-?NEW
Nor TITLE NO_6o5-s-go24 GUAIZANTEED_TO ME F125T /��. ��v�op .C.'.1
coN-rcU2_5_s>~-rt R,. !0 SUET= tiO. D.P•ts.oJ AE; iis,l_ AME2IGAN TITLE t\ISU ANLE W.1 '�Ye. r, T.6..4; • '''f;
J25r'E:�!, DATUI-t:NrA tai SEA LE4'E! A5 S'.1�JEYr G AP2.9,; O ,r:i,�y r Q _
RO_DERI K VANJUYLI .C. �'
/dam. V-......_ /_ �cr' 1,O 6"
NEIGI-IBOIZING WELL A CESSPOOL LOCATIONS REPORTED BY OWNERS,
y'OLANoc'J "
LICENSED LAND SURVEYORS l7' _ <
,t • rr___ BUILDINGS APPP.CX. GREENPORT NEW YORK
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