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Home My WebLink AboutGroup for the East End (2) 1�i.IZA 15'Y'Ii A.NEVILUK `�►1i4f SO(/ryo Town Hall,53095 Main Road TOWN CLB ,`O �D P.O. Hoc 1179 REGISTRAR OF VITAL STATISTICS Southold,New York 11971 SAGE OFFICER Fax(631) 765,8145 RECORDS MANAGEMENT OFFICER Telephone(691) 765-1800 FREEDOM OF INFORMATION OFFICER � southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 4377-N Residential Non-Residential X Fee $ 25.00 New Existing X Name Of Owner GROUP FOR THE EAST END ------------------------------ Mailing Address 1 PO BOX 1792 ------------------------------ Mailing Address 2 ------------------------------ City St Zip SOUTHOLD NY 11971-0000 ---------�---------- -- ---------- Property Address 1 54895 MAIN ROAD ------------------------------ Property Address 2 ------------------------------ City St Zip SOUTHOLD NY 11971-0000 -------------------- -- ---------- Owner Telephone No. 000-000-0000 ------------ Tax Map No. section 62.00 block 1 lot 4.000 ------ --- ------ Cross Street YOUNGS AVENUE ------------------------------ ---------------------------------- Issue Date: 9/23/08 Elizabeth A. Neville -------- Southold Town Clerk (TOWN SEAL) �oF sorry ELIZABETH A.NEVILLE �0� �l0 Town Hall,53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER G Q Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER �liy�+ou southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION OPERATION PERMIT CESSPOOL or SEPTIC TANK ❑ Residential @ $10 orPon-Residential @ $25 Application No. Permit No. Owner Name: G t ti E S S-+ a,-, ,K 3 Owner Mailing Address: P. O ►j po X _/ Propery Address: S 9 � M Q J Owner Telephone No. Tax Map No.: Section: 2 Block: Lot: Nearest Cross Street: A v r LA_X05 r-C, Please check all that apply: E] New Construction XAlteration to existing system ❑ Residential @Non-Residential r«� e CA Sokfi4481J NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate building and system; give north arrow and approximate distance in feet from system to building and closest road. New ocnstruction may submit a copy of s ey with SCHD approval.) 'Y '041el < L :)-I08' Siganture of Applicant Date Received by: TKF Excavating & Demolition, Ltd. 4 Pepperidge Lane East Moriches,NY 11940 631-878-2700 Phone/Fax CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER Health Department Reference Number C 16 — 6 -7 —0 0 t Q Suffolk Tax Map#Dist. /(?(�C3 Sect(s). f p, Blk(s). U 1 Lot(s) 0�J Project Name or Address: Eyf 4 9�j V✓X v� 5 -t- • f>oa -h v ICA Subdivision Name&Lot#: Applicant's Name: &n Ka,I 'o 6 rl--- LAO( Description of System Installed: Septic Tank Volume(gallons): > /o-160 Shape: ( )Rectangular (l.)eMdrical Name of Precast Manufacturer: aQ✓!t 000t f'✓ec aS t Leaching Pools Number of Pools: Diameter&Depth: $��c /I;t _ Name of Precast Manufacturer: Q li11b n P�� s Other: Attach or sketch below the measurements from building corners t the access covers of disposal system. r � 1 r I hereby certify that the subsurface s e disposal system described above has been installed by me in accordance with the approved n and star of S lk County Department of Health Services and is operational. Installer Signature:—, Date: Print Name/Company:TIM Excav mg& emolitio , Phone:631-878-2700 Consumer Affairs License Number: 31742LW Suffolk Uounty Department of neanu aCr vncca. Office of Wastewater Management Suffolk County Center Riverhead,New York 11901 (631)852-2100 CERTIFICATION OF SEWAGE DISPOSAL SYSTEM A3ANDONMENT Health Department Reference Number: l — Q 1 — 00 10 Suffolk Tax Map#: Dist: 6 Sect(s) (Q g- Bik(s)--6LL—;Lot(s)_� Project Name or Address: ��J n4 a lY S)L_ Subdivision Name&Lot# Applicant Name: 0 cLL . a I HEREBY CERTIFY THAT: 1. The first septic tank/leaching pool,from the foundation,was located and uncovered,AND 2. If liquid sewage was noted therein, was pumped dry by a licensed sewage hauler,AND 3. Tank/pool was inspected for outlet line to an overflow pool,AND. 4. Overflow pool(s) was/were located, uncovered-and items #2 and#3 were repeated until all parts of sanitary system were located, AND 5. All parts of sani�ary system were removed or filled with clean.backfill and any corbelled block domes collapsed. 1 Alsu certify that the sanitary syste n1,abandonM consisted of: First tank/pool feet diameter�,.J—feet deep ( )precast tMock ; ).other _ First overflow1?ool--(�P feet diameter feet deep( )precast ( rock ( )other Next overflow pool feet diameter feet deep ( )precast(. )block ( )other Next overflow pool feet diameter feet deep ( )p�ecast( )block ( )other Company which pumped out sanitary system if different from ertifying company: Name of Company: Address: -mac U Consumer Affairs License Number. _ f� Contractor Signa Date f O &!0 e Print Name/Company: ca a � _ It" ova Phone &3i -;r7 8 -2 700 Address: k Pe )P 4 i d-V � iS 4 V71 Lt t)0 � Consumer Affairs License Number: I `7 L,1 o- —1..I,e) This certification shall not be used in lieu of inspections required by personnel of the Department and may be duplicated on company letterhead,provided it contains the above information. WWM-080 (Rev. 12101)