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ELIZABETH A. NEVILLE,MMC �y�� cam , Town Hall,53095 Main Road
TOWN CLERK P.O. Box 1179
= Southold,New York 11971
REGISTRAR OF VITAL STATISTICS • Fax(631)765-6145
MARRIAGE OFFICEROl �a0! Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www.southoldtownny gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
rD;i
TO: Southold Town Building Department DEC
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: December 6, 2017 TO ri4 OF SOU1 1:ILID
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4547 for a Cesspool/Septic Tank Construction
Permit submitted by:
John & Maureen Hurley
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
V
DISAPPROVE
Comments: Final approval required from the Suffolk County Health Department
Signature
Dated
a 2n. a1
ELIZABETa A. NEVrLLE � '- Town Hall, 53096 Main Roa,
TOWN CLERK @ P.O. Box 1179
Southold
REGIST OF VITAL STATISTICS
New York 11971
MARRIAGE OFFICER `"' Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER �: ! + Telephone (631)766-1800
FREEDOM OF INFORAA.TION OFFICLIt "" Sou tholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @$25 Application No. �
P ern_lxt No. __.._.W...
Applicant Name
Applicant.Mailing Add �...� �5 "
pp g res .�A..._ .W . .. C
Septic Tankor Cesspool
ucton or AlterationBrief Description of Proposed Constri
�
_....... "y" mmr
Location of Proposed Construction/Alteration:
r
Owner of Propert),r: _.0 17, °1
Owner Mailing Address; _ �i"ViLC
e
ai
Owner Property Address:
Name and phone number of contact personL6
G4,
Tax Map No: Section_/��Block _ t ._..._/ .
r
Cross Street
NOTE: LOCATION MAP MUST*BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVP;Y)A"ITI ISA ,,TQ DEPARTMENT APPROVAL
igaafiire of Applicant Date
Received by: ..w ._. _ ..
PROJECT
.. LOCATION
LOCATION MAP
1. 00'
SUPFOLK COIJY DEPAUR N!ENT OF Hl EIA
IIT FOR PO&AOF CONS, RUC'-,'CN Flw
SmNGLE FAmILY RESEDENCEONLY
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y 4,
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om t
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- - CO = �O�=g CCrit .� #
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compicted 0_.=� i
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OLT ML
UD SAA
0 SP
27 0#GH!EST EXPECTED)
)TOWN FINE SAND SP
N SILTY SAND SM
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BROWN FINE SAND SP By HEALT4
NCE DATED JULY 7,2010.
D 15.T BELOW GRADE
HEALTH DEPARTMENT APPROVAL STAMP
NERAL NOTES
ALL MATERIALS AND METHODS OF CONSTRUCTION SHALL CONFORM TO THE STANDARDS AND SPECIFICATIONS OF THE TOWN
DF SOUTHOLD AND THE SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES AS REQUIRED.
BOUNDARY AND TOPOGRAPHIC INFORMATION FROM SURVEY BY PECONIC SURVEYORS DATED JULY 12,2017. ELEVATIONS ARE
REFERENCED TO THE NGVD 29 DATUM. FEMA FLOOD ZONE FROM FIRM 36103CM81H.
IHE CONTRACTOR SHALL FIELD VERIFY THE LOCATION AND DEPTH OF ALL UTRMES PRIOR TO THE COMMENCEMENT OF
0RK. THE CONMCTOR IS ADVISED ALL SUBSURFACE INFORMATION SHOWN ON THESE PLANS IS CONCEPTUAL AND MUST
X CONFORMED ACCORDINGLY IN THE.FIELD.
4 MINIMUM SEPARATION OF TEN(10)FEET HORIZONTAL AND EIGHTEEN(18)INCHES VERTICAL IS TO BE MAINTAINED BETWEEN
NATER LINES,STORM DRAINAGE AN010R SANITARY LINES OR STRUCTURES
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