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ELIZABETH A.NEVILLEa Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
Southold New York 11971
REGISTRAR OF VITAL STATISTICS Pry t
MARRIAGE OFFICER liL � ���, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER � 4/Ql .$ ,,• Fax
(631) 765-1800
FREEDOM OF INFORMATION OFFICER ,s'� 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. 3034 R Residential X Non-Residential
Fee $ 10,00 Septic X Cesspool
PERMIT ISSUED TO:
Name : MARK HAYNES
Address 1: 38 DURLAND ROAD
City St Zip LYNBROOK NY 11563
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 #R10-03-0053
Name Of Owner HAYNES, MARK & CARLA
Mailing Address 1 38 DURLAND ROAD
City St Zip LYNBROOK NY 11563
Property Address 1 4270 THE LONG WAY
City St Zip EAST MARION NY 11939
Tax Map No. section 30.00 block 2 lot 95.000
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 6/11/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
illos�fFO(,� 303q
ELIZABETH A.NEVILLE /0 OGy • Town Hall, 53095 Main Road
TOWN CLERK p P.O.Box 1179
%REGISTRAR.OF VITAL STATISTICS I�;, Southold, New York 11971
MARRIAGE OFFICER . Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =y�fo a��ii•� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
E 1 = OFFICE OF THE TOWN CLERK
MAY1 141x4" ; 'j TOWN OF SOUTHOLD
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'Ty! �.i= ` Lig
Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3158 for a Cesspool/Septic Tank Construction
Permit submitted by:
Mark A. Haynes
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: I ,0"'" _
Signature
5/513
Dated
4
OFFICE OF THE TOWN CLERK ,'
TOWN OF SOUTHOLD �,�' S��fD eQG Application No. 3 /Sor
ELIZABETH A.NEVILLE,TOWN CLERK O•
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971 aT
• Alteration
Telephone , 0,4 �Q��', $10.00 -Residential
(63t) 765-1800 — Ol, �� $25.00 -Non-Residential
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for •
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL •
Permit No.
Fee .$
DATE A°1', Co • 03
APPLICANT NAME: t--tuft &. 14.411ti1g5 ,
APPLICANT ADDRESS: *lg m,RLS t t=> 120,6;
Lys 13 206ic r1.-(. U 5(03
SEPTIC X CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
NFL) S+►-1C=N-S' 6 W*AE .rvrn4 4 ISEVORt..A.S
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
. OWNER OF PROPERTY: to 21G CA-14
OWNER MAILING ADDRESS: 3$
L11Jsecxac. t•'-f. 1lSC0,
OWNER PROPERTY ADDRESS: 42,-10 -rue Loth e,.),str
t--e.524o11/41 . 1,1--e.
TELEPHONE NUMBER OF CONTACT PERSON: Si(o• 86/ • 3(001,
TAX MAP NO. : Section 3o Block 2. Lot 0,5 •
CROSS STREET: -MT wg-f
BUILDING PERMIT NUMBER CROSS REFERENCE: .
- 1
Signature of p !cant
RECEIVED BY: 4,- .1/0/`-- •
o ' CI k's Office
DATE: �` /6- /
P
t -\
r
am familiar with the STANDARDS FOR APPROVAL
VD CONSTRUCTION OF SUBSURFACE SEWAGE N i
SPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES SURVEY OF PROPERTY
id will abide by the conditions set forth therein and on the
ermit to construct. "-ilk;'' AT EAST MARION 3
Te location of wells and cesspools shown hereon are TOWN OF SOUTHOLD
om ffd observations and or from data obtained from others SUFFOLK COUNTY, N.Y.
IY ALTERA77ON OR ADDITION TO THIS SURVEY IS A VIOLATION - Z
SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. E p 1000-30-02-95
(CEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS SCALE. 1 =40'
:REON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF Z C7 NOV. .' 2002
'-4
AID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR EL 6' N 0 DEC. 13, 2002 (prop. hse. 1
HOSE SIGNATURE APPEARS HEREON s
� � JAN. l 7, 2003 s�ser�
levotions referenced to an assumed datum \ LOT 6� C WAjER) 31368 FEB:"5, 2003 (prop. hse. 1
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EXCAVATION INSPECTION REtaU113ED
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'� LIC. NO. 49618,
� .EC' .''II ;1�,'1 :', P C. ,
(631) 76 - e • FAX (631) 765-1797
P.O. BOX 909
TRAVELER STREET
AREA=25,965 S.F. Lot numbers refer to "Md of Pebble Beach Forms" filed in thecJeJe�
` Suffolk County Clerk's OftO e on June 11, 1975 as File No. 6266 1230 1230 N.Y.LD, N. 11971 0rGrG_