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ELIZABETH A. NEVILLE �i Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ` Southold, New York 11971
MARRIAGE OFFICER �� �foL l�.1�1 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �__7®1 Ait ��®�.i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER 1��
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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. 2526 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : ANDREW C FOHRKOLB
Address 1 : 670 HOLDEN AVENUE
City St Zip CUTCHOGUE NY 11935
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 #R10-01-0052
Name Of Owner FOHRKOLB, ANDREW C
Mailing Address 1 670 HOLDEN AVENUE
City St Zip CUTCHOGUE NY 11935
Property Address 1 ALVAH'S LANE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 102.00 block 4 lot 5.005
Cross Street BRIDLE COURT
Building Permit Number Cross Reference:
Issue Date: 3/27/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
O
ELIZABETH A. NEVILLE �� �t: Town Hall, 53095 Main Road
TOWN CLERK y 2 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS %4/ 4,� Southold, New York 11971
MARRIAGE OFFICER �� y 1 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER -__-701 �� �0i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER •_ �,�,�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: March 9, 2001
Transmitted herewith is a copy of application No. let for a Cesspool/Septic Tank Construction
Permit submitted by:
Andrew C. Fohrkolb
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:
Signature
c3f a' /0 �
Dated
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OFFICE OF THE TOWN CLERK .••• FUCOL ) I
TOWN OF SOU ,.�� Application No. ��
ELIZABETH A.NEVILLE,TOWN CLERK G
P.O.BOX 1179 �,1Construction t ''''---
SOUTHOLD,NEW YORK 11971 : v • rn Alteration
Telephone
s-..0#
O,0 ' �O../ • $10.00 - Residential v
(631) 765-1800 �1' > `%,���� $25.00 -Non-Residential
,,,.,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION ..----
for el\IV IV)
CONSTRUCTION or ALTERATION PERMIT n 0
SEPTIC TANK or CESSPOOL x�
A icregIC9e
,4001
Permit No.
Fee .$ Z6 '/
DATE
• APPLICANT NAME: 4/VDC.6-ZU �
APPLICANT ADDRESS: 6 *70 /CA,015',L) ivy
& T )� A/y - / 9 .23
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
06aJe-1.-/_—/Itli
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CON TRUCTION OR ALTERATION: •
OWNER OF PROPERTY: iV/.0aFetfie--K0-7-6
OWNER MAILING ADDRESS: 470 ,oLpo�'iv P
Te--A/o , U A/V // 9 - ---
OWNER PROPERTY ADDRESS:
IJP 'Lt,33
TELEPHONE NUMBER OF CONTACT PERSON O-3/) 296 ---- 2 •7
TAX MAP NO. : Section t0 Z. Block ® )1 Lot �-:..c
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFER CE:
4,1 dr tr
,/ Sig - ure o Applicant •
RECEIVED BY:
Town Clerk's Office
DATE:
• Young & Young, Land Surveyors
,,,,;,. 400 Ostrander Avenue, Riverhead, New York 11:§v -
�r- _, 0\ 631-727-2303
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Alden W. Young, P.E. & L.S. (1908-1994)
Howard W. Young, Land Surveyor
O` Thomas C. Wolpert, Professional Engineer
\ J
5r 41041
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6'- S �L/S La`'e
Rs. 77,, , HEALTH DEPARTMENT USE
v' 7 F 9
is- /0 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICIES
PERMIT FOR APPROVAL OF CONSTRUCTION FOR A
Fac �`Sl`p� ,`9 �` SINGLE FAMILY RESIDENCE ONLY
S
��c� Rb . , S� , DATE 1 (ot H 1< E 0. 'R)4 a) -- DOEa,
+ , lc i
o
411 /C0 9 ®r9 ®a�RO0e
d �� EXPIRES THREE YEARS FROM DATE OF1, ...i
6'• ,Do � c.
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��0co +\ c ° 6s SOA NOTE
J �� +04. l.). ,>,
�j 0/P 1 AREA = 83,837 SQ. FT.
+ �� '6) • LOT NUMBERS REFER TO "SUBDIVISION PLAT — RICHARD
\�cF QS/ REINHARDT" FILED IN THE OFFICE OF THE CLERK OF SUFFOLK
<` , +NN & COUNTY ON AUGUST 18, 1999 AS FILE NO. 10325.
°o +\ VERTICAL DATUM = N,G.V. DATUM (M.S.L. 1929) ,
\\
•'ham - •�� SURVEYOR'S CERTIFICATION ,
0 \ ,
`• • WE HEREBY CERTIFY TO ANDREW C. FOHRKOLE
r7002, to \ THAT THIS SURVEY WAS PREPARED IN ACCORDANCE WITH THE
,^ \ CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW
.. 19a3, . N
_ _
''.. YORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS.
BVI AR 1266' RI;
�- NEIN
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/ °gyp HOWARD W. YOUNG, N.Y.S. L.S. NO. 45893 aii
N \ °Hcy \ j j 4589�� ,-
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