HomeMy WebLinkAboutTohn 0o G*4
JUDITH T. TERRY % .04
Town Hall, 53095 Main Road
TOWN CLERK ® r� P.O. BOX 1 179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
® Fax (516) 765-1823
MARRIAGE OFFICER
14®1 sild �g�►r t� Telephone (516) 765-1801
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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. 1091 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : THOMAS AND SHARON GOELLER
Address 1 : P. O. BOX 426
City St Zip REMSENBURG NY 11960
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF #R10-94-0005
Name Of Owner TOHN, THOMAS
Mailing Address 1 23 FOX RIDGE LANE
City St Zip LOCUST VALLEY NY 11560
Property Address 1 NEW SUFFOLK AVENUE
City St Zip MATTITUCK NY 11952
Tax Map No. section 115.00 block 4 lot 8.004
Cross Street MEADOW LANE
Building Permit Number Cross Reference:
Issue Date: 2/15/94 Judith T. Terry
Southold Town Clerk
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JAN 2 G 1994
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JUDITH T. TERRY I� m ,]' ti `° k: >•Town Ha11; 53095 Main Road
t TOWN OF 0iis."s:tiEacJ' --.-P:O. Box 1179
TOWN CLERK : '_r � r- �— v.
fili a i Southold, New York 11971
REGISTRAR OF VITAL STATISTICSNr. ,*1' Fax (516) 765-1823
MARRIAGE OFFICER � �i` Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER _ 0°
FREEDOM OF INFORMATION OFFICER ----„„�ir1-'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: January 25, 1994
Transmitted herewith is a copy of application No. 1126 for a Cesspool/
Septic Tank Construction Permit submitted by:
Thomas and Sharon Goeller for Thomas Tohn .
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.
d �
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recom/mendations:
APPROVE
DISAPPROVE /�
Comments: f �C' Z) /C //'l'—IT�/,
craoC-
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Signature ir
/ I 9
Dated
f-' - •-
yr OFFICE OF T`HE TOWN CLERK cOFOU' _
Town of Southold - ` CDS Application No. //o��
Judith T. Terry, Town Clerk ht-
Town Hall, 53095 Main RoadY �Lx Construction `J
P. O. Box 1179 O ® Ly �, Alteration
Southold, New York 11971 0 "'
Residential ‘�
Telephone �� ��i
(516) 765-1801 "'
'; ;Non-Residential
r '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DIST4CT
"I
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL-
Permit No. -
Fee $
DATE '/2 5/q4-
APPLICANT NAME: -n,,,,,,,,as I . dc5ha,r j W 60e,64,----
APPLICANT
ADDRESS: 70. (2O>( o ( 6 C[a L.4.0..)
7-Zumse mbui1 t! V 11'76 0 .
SEPTIC `CESSPOOL V
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
. Nfe/w 31kr131,e 4ty-oauf gt,w-ethmi .
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: I lioncia(5 (Dhr
OWNER MAILING ADDRESS: 273 Fax ZIGQ ' A 0-Q�
1 ,usi- Va.11 , N \,/ itS60
OWNER PROPERTY ADDRESS: t]tj SL -Lk- 4iJ-p t
TELEPHONE NUMBER OF CONTACT PERSON(Ap47(LC ) $76/2-R-8-21-131TAX MAP NO. : Section 4471:11- Block c115- 4 Lotg,
CROSS STREET: v_a_do,n) LCC,V1
BUILDING PERMIT NUMBER CROSS REFERENCE:
Al,(4,64-)40--gd' ///
Signature of Applicant
RECEIVED BY: (../W
ilke--1----;
Tpwn Clerk's Office
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TOPOGRAPHICAL MAPS PREPARED BY OTHERS AND �� S' �'
REFERENCED TO MEAN SEA LEVEL DATUM. SC�\• ,
SURVEY FOR NIc4
THOMAS G. GOELLER a SHARON W. GOELLER
SUFFOUC COUNTY DePARTMENT OF HEALTH SERVICE
AT MAT TIT UCK DATE DEC.29,1993
FOR APPROVAL OF CONSTRUCTION ONLY TOWN OF SOUTHOLD SCALE 1".50'
DATE�AN 21 Q OOO SUFFOLK COUNTY, NEW YORK NO 93-0977
HS REF. NO,(h/0-g—C6C) MWYUTNOIIIZED ALTERATION ORADDITION TOTHIS CERTIFIED TOI
n SURVEY D A VIOLATION !X<SE CTION 7200 OF TMC
�i �)//� NEW YORK STATE EDUCATION LAW THOMAS D.GOELLER
APPROVEQ, �74�A 4 C�✓ti414, *COPIES OF MIS SURVEY NOT BEARING THE LAND SHARON W.GOELLER
! SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL GREEN P VINGS BANK
•
i NOT BE CONSIDERED TO BE A VALID TRUE COPY
I IIGUARANTEES INDICATED HEREON SHALL RUN ONLY TO NEW
HEALTH DEPARTMENT DATA FOR APPROVAL TO CONSTRUCT THE PERSON FOR WHOM THE SURVEY IS PREPARED •V
I AND a HIS BEHALF TO THE TITLE COMPANY,GOVERN-
•NEAREST WATTS WAIN MI! N SOURCE Of W PRIWTE_PUBLIC— MENTAL AGENCY AND LENDING INSTITUTION LISTED ��w' YO O
N WI CO TAD MAP DIST_000 SECTION IIS BLOCK�_LOT_@4_ HEREON.AND TO THE ASSIGNEES OF THE LENDING T' G
*MEP. ARL HO OWLLLINSf WITHIN FDO FELT OF THIS PROPERTY INSTITUTION GUARANTEES ARE NOT TRANSFERABLE W
OTHER THAN THOSE SHOWN MERLON TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT y
OWNERS xI�•..I1
N THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENCE I I
WILL CONFORM TO THE 7TANDAN0S OF THE SUFFOLK COUNTY DEP M DISTANCES SHOWN HEREON FROM PROPERTY UNEP uj( f�;
OF HEALTH SLMICLS /�I, TO EXISTING STRUCTURES ARE FOR A SPECIFIC '''''%.4"-1,
t�.,_• /�
A1fLICyl7f�f� µ�I tT,���0 1� l PURPOSE AND ARE NOT TO BE USEDTO ESTASLISH
'�U
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AODRE 6 (e c Lc Lanvl eewlsexb(•u-0 N y �rD(A f �
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•NOTE• ♦ D STAKE FOUN• D 6:STAKE SET
RE LOT I R-SUBDIVIS ION FOR"SET-OFF ALDEN WYOUNG,PROFESSIONAL ENGINEER
ANO LAND SURVEYOR N YS LICENSE NO.12845
JOHN J MISKA"1• HOWARD W YOUNG, LAND SURVEYOR
I TIE L TM OF W¢LIWI,SEPTIC TAPRISTIB CLSSPOOLSCO)!MOWN MASON N Y S LICENSE NO 45893
MK PROM FIELD 041011111010011 ARK)OR DATA OBTAINED FROM OTHERS
aRAN015 A SONS INC. i 1