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ELIZABETH A.NEVILLE,MMC Town G� Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
vs Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ® Fax(631)765-6145
MS M NAGEMENT OFFICER GE OFFICER �'�A� ®� Telephone(631)765-1800
RECORD
FREEDOM OF INFORMATION OFFICER �'�'��'•southoldtownny.gov
OFFICE OF THE TOWN CLERK D
[EC[EDV DD
TOWN OF SOUTHOLD
MAY 3 1 2017 ,
TO: Southold Town Building Department
BUILDING DEPT.
FROM: Sabrina Born, Southold Town Clerk's Office TOWN OF SOUTHOLD
DATED: May 31, 2017
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4490 for a Cesspool/Septic Tank Construction
Permit submitted by:
George Starkie
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and return it to me. Thank you.
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments:
Iva
Signature
49 3
Dated
���®��F
ELIZABETH A. NEVILLE Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
esu Southold, New York 11971
REGISTRAR OF VITAL STATISTICS r 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 DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
r:
Residential @ $10� or Non-Residential @ $25 Application No. ke
Permit No.
Applicant Name (2g2?r �
_ 1
Applicant Mailing Address q_q y za 1
v P A LLQ �2
Septic Tank or Cesspool=
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: I
Owner Mailing Address: t 9
Owner Property Address: jC �i:t Lqne � =
Name and phone number of contact person
Tax Map No: jOt Section_ Block Lot C < '
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of A licant Date
Received by:
84.0 ' INV c�16 0 c.; (3220) Lf)
i (32.00) ---------
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:i_, INV. �
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IN.V_._ '\`ll�V 50 5.4' o
5.0 ; (27.60) (28�21� 11.15'
5.8' 0 0
MIN. ;Fo 10.0 va ��� r
Y
0 .
PROP. EPTIC SYSTEM (2y o b MIN. �� '� .
EXISTING SEPTIC SYSTEM 3 ! 1.5' PROVO-SED r< .0'
TO BE FILLED & ABANDONED 5 BEDROOM
IN ACCORDANCE WITH `t --------
® SCDHS SPECIFICATIONS I� 1.5 2 STY. HOUSE Q, ,
t-- - - ;D,,; a i (34.00) F. fZ. 1 .0
W 5.0 Ld
N UY U > CN
o
HOUSE %fc�o
"of Lo- 11.15'
d ; TO BE Q3 6.2l
f,�/
REMOVED j rYj� S
V (3220)
(3200) 12.5 24 9'
20.9
�_J
CABLE co
_ _i o.H EJECT., PROPOSED
0
PROP. N 3I CAR GARAGE
Q E ISTING WELL OR IRRIGA11ON ONLY � 2 fJ0) FL. 31.
p utility (32.00)
o' pole OT FOR DOMETIC USE _ __ _ 0 12.9'
(32.00) o
DIRT ROAD -
_ - PROPOSED DRIVEWAY (PERVIOUS'- -
I
� I
20' SET BACK `r s
150.0
I
i , I
REBAR el.30.0
jo TEST
el.30.5' S 46035'50" W 211. ®O' DOMEOSE HOLE
STICWATER WELL
FOR NEW RESIDENCE
N U R S E R Y
F I E L D
co
N
c
i
1-1% GENERAL SITE P1
'AIN ROAD (S. R. 2o)
SCALE: 1" ® g®