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ELIZABETH A.NEVILLE t4 Town_� �'�. Town Hall, 53095 Main Road
TOWN CLERK ; y = ; P.O. Box 1179
cf.,REGISTRAR OF VITAL STATISTICS 1 Southold, New York 11971
RECORDS
Fax
31) 765-6145
N
MARRIAGE
MANAGEMENT OFFICER `-y�f1 a;Stsw el��, Telephone (6 1 ) 765-1800
FREEDOM OF INFORMATION OFFICER ,,s'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2498 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : THOMAS DUNN GENERAL CONTRACTOR
Address 1 : 1 FOREST AVENUE
City St Zip LAKE GROVE NY 11755
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 # R10-00-0227
Name Of Owner GRIMM, JOHN B
Mailing Address 1 60 I .U. WILLIS ROAD
City St Zip NEW HYDE PARK NY 11044
Property Address 1 COUNTRY CLUB DRIVE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 109.00 block 3 lot 8.000
Cross Street LINDEN AVENUE
Building Permit Number Cross Reference:
Issue Date: 1/22/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
0111,cOFFOLir c) 1(;\, .
ELIZABETH A. NEVILLE ���� �'�A: Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS % PrtSouthold, New York 11971
MARRIAGE OFFICER ' r ���1, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = �®i .,,,. ,011. Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER 1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: January 10, 2001
Transmitted herewith is a copy of application No. 2586 for a Cesspool/Septic Tank
CONSTRUCTION/ALTERATION Permit submitted by:
Thomas Dunn General Contr. For John Barry Grimm
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Maintain required setbacks from adjacent wells,buildings,property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
ignature
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Dated
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OFFICE OF THE TOWN CLERK •'..'�,i••'C••••••,���;
•
TOWN OF SOUTHOLD ,,'Q''' I ��KCQ� - Application No. 2S'3(
FI.T7ABETHA.NEVILLE,TOWN CLERK ,i L§.,. y.1
Construction
P.O.BOX 1179 z }.
SOUTHOLD,NEW YORK 11971 . = Z Z
• Alteration
Telephone b,� �Qr,''$ . $10.00 -Residential Q -
(G31) 765-1800 --- - 1 ',•'' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
' APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
DATE 18 q 40 n 1
APPLICANT NAME: - .►1k6 If(/t. 4 s bulk, ki COeDU0PAC 00 A) I , i k, (2-
APPLICANT ADDRESS: 4, Pi P e c T i4
‘4..og ta. 6 ck.I. M y. //76-5:
SEPTIC 1/ CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
1U eco 14-6 c.t S Y
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR_ALTERATION:
OWNER OF PROPERTY: 7 J 6Lni `BARRY Giedvt
OWNER MAILING ADDRESS: 6 CS I .C, Lu ,,(,(,i cr 7 i7
New I(y ®eg P A Et< JUrIIo ' /
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 6 9 /-- 96' 1— ‘ 76 6
TAX MAP NO. : Section f Y9 Block 63 Lot g
CROSS STREET: 1 l iji '#P 4u
BUILDING PERMIT NUMBER CROSS REFERENCE:
•
ot--6 ()e .—,.
Signature of Applicant
RECEIVED BY: F
Aw.--
Clerk's Office
DATE: 0
9
R
y, (OGc" -
G. O�0 �� . �f- I am familiar wPh, the STANDARDS FOR APPROVAL
�l E 16vi a `N ®��I,'- AND CONSTRUCT;O�. OF-SUBSUPFACE SEWAGE
e ✓n v �i2a '� 4 :• DISPOSAL SYSTEMS r OR ShVGLE AMIL Y RESIDENCES
� : and will abide by the'conditions sdl`forth -therein -and on the
4� permit to construct.
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- �� E FILED OCT. 17,1978 1�G�1D'NO 673
0, �oP hs e (Ile �, ' ';� A T CCI TCI-IC�GI��
.0. . ` q ^��'' . �� TO W_N-OF-SOU;�T� ,tL-D - . ; .
�rogf r • SUFFOLK.CO ,1 NT Y, �N V `
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.� 1000 - 109 - 03 - 22
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` 3er Scale: 1" = 40'
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES = c
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rnr- --- - t-I
Ltk',r . ;,- 7 - -'',' PERMIT FOR APPROVAL OF CONSTRUCTION FORM �° . rt-I ;
61 1;6. 1 E FAMILY RESIDENCE ONLY �,,ri = CD m
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C e ,
o DATE 1.l7-e)0 HS REF. •O. t6 ARO-OZZ
9 P IP" e�2ti•° CiS we/ APPROVED ' /1� =�cm w .
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�l FOR MAXIMUM OF__q_B.a, 9'.MS
No. 5 9
0' F EXPIRES THREE YEARS FROM DATE OF APPROVAL
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v'L�\ �°°.A! No g�'tPi ,_s..• . ��OF NEW y0/P
°��30 1� c, J��t. METjC�� d^
The locations v/ wells and cesspools 59 O = S .f t. '9w
shown hereon are from field observations „ a 5. �� 1�,r�o AREA40,426q 3 &„
and or from data obtained from others. /a ,' vie . i- h.,,'.4,�� �H����
�E�� d' C•Q. 7. ELEVATIONS ARE REFERENCED int"°` +'- ,
ANY AL TENA TIOW OR ADDITION TO SURVEY IS'A VIOLATION TO AN ASSUMED DATUM. 0.' ,.. .*1` ��
OF SECTION 7209 OF THE NEW YORk STATE EDUCATION LAW. ` - ''' �0
EXCEPT AS PER-SECTION.T209 - SUBDIVISION-2. ALL CERTIFICATIONS ' �aL�4v 6 << LIC. NO. 496f8
HEREON ARE VALID.FOR TMS MAP.AND COPIES THEREOF ONLY F L
SAIDMAP OR COPES BEAR TIE=f111PRESSL�D-SEAL'+AF THE SURVEYOR PECONIC Se.---1"."7-RS, P.C. •, - - "
WHOSE SIGNATURE APPEARS HEREON. (63/) 765 - 5020 FAX f63/) 765 - 1797
ADDITIONALLY TO COMPLY WITH SAID LAW THE TERM ALTERED BY' P. 0. BOX 909
MUST BE USED BY ANY AND ALL SURVEYORS UTILIZING A-COPY ' /230 TRAVELER STREET
'BR��T -- TOHER SURVEYOR'S
-D T�AR NOT7IINMC�COMPLIANCE
WITH�THE'E'LAW. SOUTHOLD, N.Y. 1197/ '
,-,
93 - .103