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ELIZABETH A.NEVILLE ����� 'y Town Hall, 53095 Main Road
TOWN CLERKH ; P.O. Box 1179
CI
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V ® Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �� Fax(631) 765-6145
MARRIAGE OFFICER �1
RECORDS MANAGEMENT OFFICER � ®1 ��® � 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. 2898 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : JOSEPH POLASHOCK
Address 1 : 86 FRANKLIN STREET
City St Zip NORTHPORT NY 11768
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 #R10-00-0036
Name Of Owner POLASHOCK, JOSEPH
Mailing Address 1 86 FRANKLIN STREET
City St Zip NORTHPORT NY 11768
Property Address 1 JACKSON STREET
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 117.00 block 9 lot 26.000
Cross Street 2ND STREET
Building Permit Number Cross Reference:
Issue Date: 9/24/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
H r ), f rnl I` 11 '7 f a i :\
.,a //��'S�Ffot�-/: I �;lH -, 17 2002 ,;' 1 f/��/J/
4. 4 is •
,/I/0N0 6re V
ELIZABETH A.NEVILLE ,tl_ y� I , T- own Iall;630915 Main Road
TOWN CLERK o I L ' T::),./7L.:-) _„ __-itJ . Box 1179
` y ' �JSouthold, New York 11971
REGISTRAR OF VITAL STATISTICS ‘`1 / 47$
' '
MARRIAGE OFFICER `. 4% 00' / Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ®1gmg $ sof Fax
(631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ,go' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: September 16, 2002
Transmitted herewith is a copy of application No. 3009 for a Cesspool/Septic Tank Construction
Permit submitted by:
Joseph Polashock
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 V ,
DISAPPROVE
AI
Comments: -. ' 11/(/'‘-'44', 7'\ cde,,,,,,-12�
Signature
0 9/g/e2-.
Dated
IL�7
OFFICE OF THE TOWN CLERK td,,i,"„"••�
FTI7ABETHANNEVAiF OWN CLERK •�• �5vFF0[kOG� Application No. 30°,
TOOF SOTHOLD
P.O.BOX 1179 O /
;
SOUTHOLD,NEW YORK 11971
Construction L/
c/1 yc Alteration
Telephone O,y ��'�•� $10.00 - Residential X.
(631) 765-1800 =��,� t �,��
$25.00 -Non-Residential
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Permit No.
•
Fee .$
DATE 40/(p/0,Z
APPLICANT NAME: epk` l o,cc. S [Lc) Etc.
APPLICANT ADDRESS: I 'elf iS�-
D-i p& , /19. an
SEPTIC CESSPOOL DC
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION Aid 3Q c.
yXY7,.41.-t. '44 5; J- 02 cS 1 izg. /C4‹ (.44, e It! ,
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATI N:
OWNER OF PROPERTY: �
�O J Qpp h !"D lames. fir'a'
OWNER MAILING ADDRESS: g% 601, 41Sx.
e o65; ).' /1,67
OWNER PROPERTY ADDRESS: w-it eC-11dZsOA, 3Y;
P 3tc..
TELEPHONE NUMBER OF CONTACT PERSON: 4 /'- 175-44-6—Wo?
TAX MAP NO. : Section Block Arra Lot - -/ 1_ 24
CROSS STREET: rTdtse�3Q®t w 2 , ��((� I
BUILDING PERMIT NUMBER CROSS REFERENCE:
oLikosk
Signature of Applicant
RECEIVED BY: It -�
Town Clerk's Office
DATE: 9I2'
TI
1-. --- —_ -_-- — —_—
aP
SURVEY OF PROPERTY =—,„,
z; SITUATED AT
:-.1-
m MICHAEL/SIMON N/O/F NEW SUFFOLK
3 a & SHANNON SIMON MICHAEL VANGI N/OAF TOWN O F S 0 U T H 0 L D
oW DWELLING & ANNA VANGI HENRY VICTORIA •
SUFFOLK COUNTY, NEW YORK
(USES PUBLIC WATER) DWELLING DWELLING- ,�;
(USES PUBLIC WATER) Y
f'- S.C. TAX No. 1000-117-09-26
WELL
-- -- ,..,1,—CESSPOOL �; SCALE 1"=40'
° I NOVEMBER 23, 2000
e U3 0 ;3� I ' N . 7FEBRUARY 15, 2002 ADDED PUBLIC WATER SERVICE
°' �I ; APRIL 17, 2002 REVISED PROPOSED HOUSE
S 85°27'10” E 2 �� c�
FOUND , e �.,
AREA = 26,765.46 sq. ft.
x CONC MON GARAGE FRAME 151 .77' - �, [1 �I lip F,� 0.614 OC.
4 5'N GARAGE F4 � g:
w a ' CHAIN LINK FENCE GARAGE o�f
' e N> _la - 4 4'N FENCE a �'
FENCE _ ., J
c a I` O L N/S 0 2'E _T 48' .G.6� °L N/S OLE/W ! v�'1 ) al nn"'
Cc- V if)
LLLJJJ � �' �� NOTES
"3 (o a P OSEv NI 'fl 0
- oI 0 et] �� "1 t4 1. ELEVATIONS ARE REFERENCED TO N.G V D. 1929 DATUM
w m ' ' ' `f� I.w EXISTINGEF.TELCEVATIONSC ARECI TSIHOWN THUS--5i2
p a w 9s z� I CO '�4 yi ey''�y 3'V P 2 111 TANK, 8' LONG,
4K 3 A WIDE, 6.-7"FOR DEEP BEDROOM HOUSE IS 1,000 GALLONS
I„ 0 112 `--- '� 3. MINIMUM LEACHING SYSTEM FOR A BEDROOM HOUSE IS
N t� 3 64' - o 1 STORY per m1 5 POOLS, 2' DEEP. 8' dla
° >.w _ f FRAME N y
BUILDING lo, ti a.1 1<a
e 20 2 (dl0'.y�'��PROPOSED EXPANSION POOL
PKGPO--' X:WE-WAY col �'
m _ pe, 9! 'P /,) PROPOSED LEACHING POOL
�+ P'
--.-_,___ f— e O ty � ' �.✓ p 'J: i ® !'PROPOSED SEPTIC TANK
t w �-STONE PIL --� 0 Cbz] N ��+ �����(r I U \ '7 4 THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD
�' IIIIIENFRoposew
52' 59 _pr i..,w I _ o-.,� OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS.
� a� 5. THIS PROPERTY IS IN FLOOD ZONE AE (EL. 8)
>' •/S� WATEJ2 LINE u ® ' FLOOD INSURANCE RATE MAP No. 36103C0501 G
eF_ ! I _ w N ZONE AE BASE fLOOD ELEVATIONS DETERMINED
I- vm UW w �' j .. 5. THE PROPOSED SEWAGE DISPOSAL SYSTEM SHALL BE EFFECTIVELY DUG OUT. DOWN TO
a''I oa 13 p a , 0 HOLI5E S - "T a) �' A SIX (6) FOOT STRATA OF ACCEPTABLE SAND AND GRAVEL. FOR A DIAMETER SIX (6) FEET
- -' EL 3 __ GREATER THAN THE LEACHING POOL. '
z u z Z 6 AREA OF EXCAVATION TO BE BACKFILLED WITH ACCEPTABLE SAND & GRAVEL
CD U <
I w 40' O Q u_ _
= ' w Lo TEST HOLE DATA
J d ° W w y TEST HOLE v Z j 3 R
3 T I� ? p, °,,, (TEST HOLE DUG BY McDONALD GEOSCIENCE ON SEPTEMBER 20, 2000)
0
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J \ E� w
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¢ V r _- 8• o
u'�,.ei Q C/1 MIXED Loan
�g0 O ""e O / 35 `I o I
I O ' e NAM SAND -7 C�� 4...=
,WEA/ <° I '- O ' -
°, Z :�� � � Oa DaaK GREY oRaw,c cur oL ��� � �
Po FEN 1 (n F, o s'e•,��41" 6 4 F-)F9 —._ ,ry
65't w
�� GREY SANDY CLAY CLQ 1
•. _ �"�--_ A h 0 3'N 0 4'E 1'a' TO HWM rrrr WATER IN GREY SANDY cur CL " _ ell
iii
' "�' F,� P a 1f A x THE a
C'AIN LINK FENCE • 71_ �,L.' T'OR -
FOUND 4.7a N 85'39'00" W W �l�.! �F• !
5a " " N 85°39'00" W ---_50—_66'_ , ." 51 ��.-".Aa
�v \UTILITY CUY PARKING BY FOUND C5 �3 * r, y i,t i
POLE WIRE 4 4, e PERMIT 1 51.93' 6NSE PIPE OMill - ®� , c��
/ 0 4•W ., = TO COR PAIS eROYM rINE 'ts
° .5.22 SIGN 3 TO COARSE SAND SW ���uuirr�,�
�O/ °,° e °e. e. e EDGE OF PAVEMENT ..1,L4 C.) 0. >. I _ i r ,.
FOUND O, �i f�'1 x.L.`t9 '.L '�, 15 �'sy�i�.`,1� ' -` '''"
GRANITE MON $II R E - ° �.'SS'' : �2
WELL C .� " ...
,,°'
N Y.S. LIC No 49668
Z o 3 TOTTHISOSURVEY IA ALTERATION IATIONADODFTION
J fir
4''. C SECTION 7209 OF THE NEW YORK STATE
TOWN o o EDUCATION LAW Jos -ph A. Ingegno
C) BEACH
VACANT COPIES OF THIS SURVE MAP NOT BEARING
F !�- THE LANE SEAL SHAL INKED SN
OR Land Survey-or
EMBOSSED SEAL SMALL NOT BE CONSIDERED
TO BEA VAUD TRUE COPY
'CERTIFICATIONS INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM T!AE SURVEY
IS PREPARED,AND ON HJ5 BEHALF TO THE
TITLE COMPANY.GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout
- - LENDING INSTITUTION LISTED HEREON.AND
TO THE ASSIGNEES OF THE LENDING INSTI-
TUTION CERTIFICATIONS ARE NOT TRANSFERABLE PHONE (631)727-2090 Fax (631)727-1727
THE EXISTENCE Of RIGHT OF WAYSAN /OR OFFICES LOCATED AT MAILING ADDRESS
GREAT pECONIC EAY I ANY, NOTESHOMWNTAREFNOTCORDdUARANTEED 1380 ROANOKE AVENUE P-0 Box 1931
RIVERHEAD, New York 11901 Riverhead, New York 11901-0965
e