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ELIZABETH A.NEVILLE �� 0. • ��►; Town Hall, 53095 Main Road
TOWN CLERK Y{ P.O.Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ` � - � ',I� Fax (631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER =__ ® � ��' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER .�� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2760 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : WILLIAM & MARIJO SMITH
Address 1 : 1170 HENRY'S LANE
City St Zip PECONIC NY 11958
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 #R10-01-0256
Name Of Owner SMITH, WILLIAM & MARIJO
Mailing Address 1 1170 HENRY'S LANE
City St Zip PECONIC NY 11958
Property Address 1 GRIGONIS PATH
City St Zip SOUTHOLD NY 11971
Tax Map No. section 70.00 block 3 lot 9.000
Cross Street JERNICK LANE
Building Permit Number Cross Reference:
Issue Date: 3/11/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE is , 's- r,- {, '1�i Town Hall, 53095 Main Road
TOWN CLERK ` Fa-- s % P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS r�a':u h ,. �1 Southold, New York 11971
` ,� ..i �� Fax (631) 765-6145
MARRIAGE OFFICER w t,'�., 1
RECORDS MANAGEMENT OFFICER =__ e/ 0" Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ---s--..,.0.I',' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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TO: Southold Town Building Department u � '
ICMAR 5 2002
FROM: Linda J. Cooper, Southold Town Clerk's Office tvlLl i
DATED: March 5, 2002QI_oi" t
TC)'�m .,.t :'fit
Transmitted herewith is a copy of application No. 2865 for a Cesspool/Septic Tank
CONSTRUCTION/ALTERATION Permit submitted by:
William&Marijo Smith
Please review the application and location map and advise if the project has received Suffolk County
Health Depaitment 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. C7Ye--1-,,- 7x7e.s
- ' ,:. -7 \.... (eiveeL/ f .
Signature 4
OVZ2157/Olz._
Dated
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A OFFICE OF THE TOWN CLERK �l ���Or�
TOWN OFSOUTHOLD �'Q�J CQG Application No.R
FI J7ABETH A.NEVILLE,TOWN CLERKi 0
P.O.BOX 1179 Construction ./
SOUTHOLD,NEW YORK 11971o � t•
Alteration
Telephone ,y Qi',, •
$10.00 -Residential
(63t) 765-1800 �1 411 $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 I 5 O�
APPLICANT NAME: ,, `�1��'I —�� !^ � , Sj�,(�-�
(
APPLICANT ADDRESS: 11 1-1U \7ArL(5 ye--
SEPTIC L/CESSPOOL
DESCRIPTION OF ROPOSED CONSTRUCTION OR ALTERATION
l
5 \ ,—e Gt_0n-III 4,0--e,tithk,_ ec S� S'lekt
fur _ k tT"1 ctonrJue
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: MIA-0 CC)p
OWNER MAILING ADDRESS: I\ / 0
` s'IL j I 7'
OWNER PROPERTY ADDRESS: �� 6-0/,/ S elf
TELEPHONE NUMBER OF CONTACT PERSON: - de—
TAX MAP NO. : Section '/WO Block - 0 " 0 3 Lot ` 09
CROSS STREET: ( d rt[S Pa4 omq J-eriv, L(C k -
BUILDING
PERMIT NUMBR CROSS REFERENCE:
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LOW.
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gn ture o • pp 'cant
RECEIVED BY:
Town CI rrk Office
DATE: a/v,, ,
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SURVEY OF-
LOT 3
MAP OF
ESTI,
SECTION ONE
FILE No. 5337 FILED JULY 18, 1969
HARVEST
SITUATED AT
SOUTHOLD
i TOWN OF SOUTHOLD
�� , SUFFOLK COUNTY, NEW YORK
a
` reit S.C. TAX No. 00-70-03-09
r oOTy wpm' S, ;$a i 1° x �`�Q a SCALE 1 1 0"=40'
X6;1 O. OCTOBER 24, 2001
_„ \ •to A. NOVEMBER 30, 2001 ADD GARAGE TO HOUSE PLAN
IAA *0
9co
x s ° 1. v` AREA = 20 404.70 sq. ft.
c1� o E •
u' r p 0.468 ac.
st
1.0%:4411r...4
Na o \ N 69 �� �� 4 \ Tr :/IA 0 CERTIFIED TO:
r . :.
�� ��\ �. ._ -•.: : � � PECONIC ABSTRACT INC.
IWILLIAM J. 'SMITH III
#��' � .12s �' - �_ ` o� 'A (� MARIJO E. SMITH
1:
ux .------,..-- ..-..-- -,--7,--.... ---b- Ad \%1 . ‘ N'(1
PZASC. Lk.
_ \ C� 1. ELEVATIONS ARE REFERENCED m AN ASSUMED DATUM
- ms` s \ Y� �� EXIS11N0 ElEVAT10lS ARE SHOWN THUS F20
1 Q ) ,-------7---=.7:,..:-1--E.:±-:-4.-_-_, 2. INFER m FRED YAP FOR TEST HOLE DATA
��re �J
-..=-7 - - \ 3. YI}DYUY SEPTIC TANK CAPACITIES FORA 1 m 4 BEDROOM HOUSE IS 1.000 GALLONS
1 TANK; 8' LONG, (-3 WIDE, 6'-7' DEEP
r,�O - - — \ • 4. MINIMUM
POOL; 1 pPNG SISTER FORA 1 m 4 BEDROOM NOOSE 6300 sq H SIDEWALL AREA
G \ PROPOSED EXPANSION POOL
-----
Its . Z
f XL/ .0'" PROPOSED LEACHING Pool
E _ l _ .'1..4Ly 90 ®PROPOSED SEPTIC TANK
y a 5. THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD
VNO 6A Z ;O ",,� OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS.
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
_ . N.Y.S. Lic. No. 49668
•
PERMIT'FOR APPROVAL OF CONSTRUCTION FOR A o'er
UNAUTHORIZED ALTERATION OR ADMIT
�1 m MS SORVEY 6 A V101141KIH OF -�
`Y` "°"' °" "�"' `STATE Jose • h A. Ingegno
l�dGi.E FAMILY RESIDENCE ONLY EDUCATOR 1AM.
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COPIES
THE MD STHIS URVEYOR'S SURVEY IMMP NOT SEN.ORS -
/ G� EMBOSSEDmBE A, , COPY. Ian • urveyor
DATE / C2�.H.S. R ,.�;.1?, "t4:\"��_�. - a S ,�-N� xXTtIIFNCATK1Ns
INDICATED�#SHALL RUN
APPROVED / y
ONLY TO'THE FTJft THE SURVEY
ANL,/� �Y� �� s PREOMPA ON HIS TO THE
TIRE COMPANY. AGENCY AND Title Surreys - Su6diYisforts - S#e Plans - Construction Layout
LIMO;IHSIMON LIMO BOURN.MND
TO THE ASSIC NIES of TIE MEM Rini-
FOR IMAXiM i i OF_ B5DROOMS mak CERTIFICATIONS ARE NOT 1TOXSPERABlE PHONE (631)727-2090 Fox (631)727-1727
EXPIRES �(`d�i vF I3 � S�=)� i ATE®I'
APPROVAL THE EXISTENCE OF RIGHT OF WAYS OFFICES LOCATED AT WONG ADDRESS
�'"•_ �• �� 1380 ROANOKE AVENUE P.O. Box 1931
xmo *z y:u�. ANY, NOT SHOWN war GUOF ARANTEED.
ANTEED.
..._.
RNERHFlD, New Yak 11901 Riverhead, Nen York 11901-0965
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