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ELIZABETH A.NEVILLE �
��� .3 Town Hall, 53095 Main Road
• TOWN CLERK ; y P.O. Box 1179
Southold,
REGISTRAR OF VITAL STATISTICS
New York 11971
MARRIAGE OFFICER ,L �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ��"'!®1 ��®�i�� 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. 2986 R Residential X Non-Residential
Fee $ 10.00 Septic x Cesspool
PERMIT ISSUED TO:
Name : RICHARD VANDENBURGH
Address 1: 1405 OAK DRIVE
City St Zip SOUTHOLD NY 11971
Descripton of Proposed construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name of Owner VANDENBURGH, RICHARD
Mailing Address 1 1405 OAK DRIVE
City St Zip SOUTHOLD NY 11971
Property Address 1 1405 OAK DRIVE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 80.00 block 1 lot 42.000
Cross Street SHORE DRIVE
Building Permit Number Cross Reference:
Issue Date: 2/18/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
1
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ELIZABETH A. NEVILLE ��'1�� ®':" Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
ti Z
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS , t
MARRIAGE OFFICER y• ����� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER '/® �® i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ,I" southoldtown.northfork.net
•. - -- j? OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
r; ;� ' ' DEC 2 6 2002 '
1
TO: s;;'; Southold-Town Building Department
( T0'.;�__
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: December 24, 2002
Transmitted herewith is a copy of application No. 3107 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Richard Vandenburgh
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.
Signature
Dated
•
OFFICE OF THE TOWN CLERK �f ' `1ate-
TOWN OF SOUTHOLD ��'�C.J QG Application No. ,�ib
ELIZABETH A.NEVILLE,TOWN CLERK
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971 v
Alteration (�
• O : • $10.00 -Residential
Telephone ��'.
0
(631) 765-180 �;,to $25.00 -Non-Residential
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee .$
DATE DraC L . zIZ. Z-`1 1C YL
APPLICANT NAME: ,(;4_, > V ANN) cm
APPLICANT ADDRESS: v S OA-cc _
Sou `l,-f u LA ill`"' ',Let e3-!
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
(A47, riA -e p�tZ Tw.l& cam•2_ Lcp
CessP l d S
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: •
OWNER OF PROPERTY: RzowaRis VGHQ
OWNER MAILING ADDRESS: / LOS-5 q\A-v_ ,Q�o
Sou- U t 7 I.di 04
OWNER PROPERTY ADDRESS: S —
TELEPHONE NUMBER OF CONTACT PERSON: 1) L,i-- 497 7
TAX MAP NO. : Section YO Block 01 Lot `0.- •
CROSS STREET: Sz
BUILDING PERMIT NUMBER CROSS REFERENCE: .21‘irt `Z
Signature of Applicant
RECEIVED BY:
T• "'Clerk's Office
DATE: _ �r
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SURVEY OF �'�
LOTS 8 . ......,,, ,....... ........,\,....
, & 10 ��2'\
MAP OF �a�0 y
REYDON SHORES INC .
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BLOCK C -4r,e2i _61��
FILE No. 631 FILED JULY 2, 1931 �.c'
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SITUATED AT 2 .__..._.�...__.._...�..... ....�_.__� ��... ,
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TOWN OF SOUTHOLD69048,4 �, .._
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COUNTY, N-EW YORK o ,�.,w E a ,.�
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S.C. TAX No. 1000-80-01 --42 o a �:tl� , ..�2..�. :� �. ��O, i
SCALE 1 "=20' - o/ Lop, �t � �:9�f .�.,s=a�,m. � -� , - .
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AUGUST 21 , 2001 . •
SEPTEMBER 18, 2001 ADDED PROPOSED ADDITIONS EXPIRES mins YEARS FROM DATE C11+APPROVAL
5, 2002 FOUNDATION LOCATION & ADDED EXISTING SEPTIC SYSTEM 5'1(
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STANDARDS FOR TITLE ' ' AS ESTABLISHED o�, •� Gti �'Cf. \ ��) �� c� \ P
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N.Y.S. Lic. No. 49668 , -
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COPIES OF THIS SURVEY AAP NOT BEARING - e - _
Land SurveyorTHE LAND SURVEYOR'S INKED SEAL OR • ry
EMBOSSED SEAL SHALL NOT BE CONSIDERED ° to �• '
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TO BE A YALfD TRI)E COPY. 1IN
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CERTIFICATIONS INDICATED HEREON SHALL,RUN �G7� �+h ' D. c 0.7
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ONLY TO.THE PERSON FOR WHOM THE SURVEY 00' ° „3�-�d.g
rrYeyS — Subdivisions - Site Plans - Construction Layout IS PREPARED, AND ON HIS BEHALF To THE o o - -,
TITLE COMPANY, GOVERNMENTAL AGENCY AND J2 - �� Ja1 Q, L�
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LENDING'INSTITUTION USTED HEREON, AND pi -
531}727-2090' Fax (631)727-1727 TO THE ASSIGNEES OF THE LENDING INSTI- . ."TI TAM nconture'nnua aoAI
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