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ELIZABETH A.NEVILLE ������® � ":.: e Town Hall, 53095 Main Road
TOWN CLERK % f ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS . Southold, New York 11971
MARRIAGE OFFICER �.® ' 01, Fax (631) 765-6145
®
RECORDS MANAGEMENT OFFICER �� � " Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER '®` ,, I"
OFFICE OF THE TOWN CLERK
SOUTHOLD VASTEMATCIESTRISTOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2622 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : WERNER L ADEZ
Address 1 : 59 HAWXHURST ROAD
City St Zip COLD SPRING HARBOR NY 11724
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 #R10-01-0121
Name Of Owner GREENBRIAR HOMES INC
Mailing Address 1 59 HAWXHURST ROAD
City St Zip COLD SPRING HARBOR NY 11724
Property Address 1 6170 ALDRICH LANE
City St Zip MATTITUCK NY 11952
Tax Map No. section 120.00 block 3 lot 8.006
Cross Street HARVEST LANE
Building Permit Number Cross Reference:
Issue Date: 7/24/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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r., soil OFF0`4° O�
ELIZABETH A.NEVILLE �� 467
e, : Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
0103
Pra i Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS ®
MARRIAGE OFFICER � / Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ;_ 'O' 4 4:0,1 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: June 29, 2001,
Transmitted herewith is a copy of application No. for a Cesspool/Septic Tank Construction
Permit submitted by:
Werner Adez
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
/ 6 t
Dated
-
OFFICE OF THE TOWN CLERK • G.11.
1 gLK n = I _�/%►
TOWN OF SOUTHOLD •' QGy .Application N•-vim•a
FI.T7ABETH A.NEWT LP,TOWN CLERK J1
P.O.BOX 1179 : Construction
SOUTHOLD,NEW YORK 11971 v T
Alteratio
elephone ��Y 410
•I/ $10.00 - Residenti•I•
(516) 765-1801 _ �l �,�" $25.00 -Non-Resi ential
...,�,,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT -
QECEIIVE
D
SEPTIC TANK or CESSPOOL
JUN 292001
Permit No. �•�..,
"•+neer- �'��rk
Fee .$
DATE 0-94/
APPLICANT NAME: a/.64/1/6e-E— 4. �/�% v6,-44", /{�" :
APPLICANT ADDRESS: 59 190, '2//es'i
e494•P /i�.e4',0,�, • /ir, // a4/
SEPTIC x CESSPOOL )C
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
asD,IST e7.-p4) 1 06,35/ L- yIJ�
6,) D.+r6ii4,y
LOCATION MAP:MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
• OWNER OF PROPERTY: �,e i ,PiG/� `t�D�l2 c /A-lc--
OWNER MAILING ADDRESS:
lil/G17 gAAes/4% /0/44149'442-7 r,/, / //V
Co110 .
OWNER PROPERTY ADDRESS: -,'„1"-74; jiG7/G/G/ G }i✓� �Sr /1
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section J� Block .3 Lot d lv
CROSS STREET: V 1
BUILDING PERMIT NUMBER CROSS REFEREN E:
Signature of Applicant
/foinEs
RECEIVED BY:
Town Clerk's Office
DATE:
.ter
e
JOB No FRMV-4 TAX LD No. 1-DOD-I20-O3-8.6
LOT 22 LOT 21
D
WELL YARD VACANT
g 25.36,30"E 4727' S 19°40'3O 77.74'
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co - 41N11 ‘114Pr
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WELL AREA co - j� �!�" ;, \! 10 >�
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PROPOSED o. �. TTS Q
22' _ SINGLE FAMILY r�i_ - - cd] , J L
65 0 CO
LOT 3 I \ 1 LOT 5 - �
OCC RES 1 SEPTIC I Q OCC RESP �!
SEPTIC FRONT-YARD J - w SEPTIC-FRONT YARD �a
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N 23°09'16"W
125.00' =g.
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?t)3.3 ALDRICH--LANE 149.5' 1 102 8
--f CO W
FILE MAP No.8808 9/1/89
CERT D1=CORRECT104
FARMLAND LIBER 11854 PAGE 27
ELEVATIONS IN-ASSUMED-DATUM LIBER 11866 PAGE 247
Unauthorized alteration or addition to this document is a violation of Section 7209 SURVEY
oftbeNeionsin State Fd ration Lam. SUTZII C i OF: L 4
Certifications indicated hereon shall run only to the person for wt>orn t isprepared
•
and on his behalf to the Title Company,Governmental Agency and Lending
Institution listed hereon,and to the assignees of the lending institutions or
M n � OF F p/'"CrF rol EU /tC-SOC IA4 E S-
subsequent owners
C'r piec of this document not bearing the professional's inked seal or emhn«ad
seal shall not be considered a valid true copy MATTITUCK. TOWN OF SOUTHOLD
TriU-CIFSEISIOr dliriemeut,a jati wrr fretcutr flute sti uc.tuteb Pj tfie',we,ty tutee 111-
for a specific purpose and use and therefore are not intended to guide the erection of
fences,retaining walls,pools,planting areas,addition to buildings or any other SUFFOLK COUNTY, NEW YORK
• construction
Theexiistence nced of right of ways and/or easements of record,if any,not shown are SURVEY DATE: 5/10/01 SCALE: 1"=50'
not CERTIFIED ONLY TO:
GREENBRIAR HOMES INC. OF IVE{�j..0.74.1/4.4.,. DEST-IN G•GR kF-
' C TRIAiQff 1 riLt t7RAME i"T° ° i; TI G.GRAF -i
-LAND SURVEYOR
,v o 73-WCYUCttawrrRvdt.t
'T .I, , t Rocky-Point,1\1.Y. 11778
By DESTIN G GRAF N Y S. LIC No. 500% 'et -631-821-3442
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