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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4445-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WILLIAM & VICKI TOTH
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Mailing Address 1 425 JACOBS LANE
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 425 JACOBS LANE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-765-6286
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Tax Map No. section 88.00 block 1 lot 1.005
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Cross Street MAIN BAYVIEW
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Issue Date: 11/15/12 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE '�At Town Hall, 53095 Main Road
cm
TOWN CLERK W Z P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICERy • �� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER l `1►aO Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
i
Residential @ $10 ✓ or Non-Residential @ $25 Application No. Y q QS
Permit No. L-;?_
Owner Name SA &21'20 (J L(1kA -T d
Owner Mailing Address G��S` :N-f�'EolQS
A r7
Owner Property AddressA
Owner Telephone No. X36--7
Tax Map No: Section ':?;% ,6 Block Lot '
Cross Street /t'( M'N 3A." V IE uj
Please check each that applies: New Construction
Alteration to Existing System
Residential Non-Residential
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 construction may submit copy of survey with SCHD approval.)
L
Signature of Applicant Date
Received by:
SCDHS Ref. # RIO- 12 - 0052 l am familiar with the STANDARDS FOR APPROVAL
ANC CONSTRUCTION.OF SUBSURFACE SEWA(GE
4O DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES
1+p S and will abide by the conditions set forth /herein and on the
• r construct.
�
permit w �6 \� S9
" .�0, mN to
f -lopO The locations of wells and cesspools
? shown hereon are from field observation
and or from data obtained from others.
Therefore their locations and or existenc
•��1� Is not guaranteed.
5�
X
>97
tr J'l
PROPOSED NEW SEPTIC SYSTEM '00,
(6 BEDROOMS) 3 a0 `
I- 1500 gal.Fy/Indrica/ SEPTIC TANK p0 / py
4- LPs 8 0 x 4 Deep with 3 sand
collar (SW) 3 'above ground Water '1, r
3- B'm x 4' LPs exiling
add 184 x 4' deep LP.
Replace 1000 gal septa lank '
/ CO
,• •tom�,�
R�yy
i
LOT�3
a W
•\ / SEPTIC SYSTEM
MEASUREMENTS
ST 11_5' 2&!;,1 Naw !
LP#1 29, 45.5 Exist.
/�. LP#2 26' Z6' Exist.
LP#3 30.5' ;29' Exist.
��• ti/ � / `\^� �P#. ? 2' 44' Now
F ` yA
MAP OF PROPER T Y
'r► f o AT
BA YVIEW
• �,� �' �� TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
1000 - 88 - 01 - 1.5
Scale: l'- = 50'
V June 28, 2012
Oct. 23, 20!2 (Septic Sys. Final)
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Z
N
EL EVA TIONS ARE REFERENCED/ TO
THE FIVE EASTERN TOWNS TOPOGRA HIC I
MAPS €
ALL IMPROVEMENTS NOT SHOWN HEREON ~ x
AREA 2. 773 Acres. , � F, ._ {
• �n 4
ANY o L TERA T7014 OR ADDI T10N TO TMS SURVEY IS A VIOLA WN r
,1��4'�" l� NO. 496/8
OF SCC TION 7P09 OF THE NEW YORK STATE EDUCATION LAW.
EXCEF T AS PER SECTION 7209 - SLl4DIVISION P. ALL CERTIFICA TIONS LOT NUMBERS ARE REFERENCED TO P CONIC SUR YORS P.C.
HEREON ARE VALD FOR THS MAP AND COPIES THEREOF ONLY IF "MINOR SUBDIVISION DEERFIELD FARM' 6311 765 - 5020 FX(631) 765 - 1797
SAO MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR FILED IN THE OFFICE OF THE SUFFOLK P.O. BOX 909
WHOSE -54"71W APPEARS HEREON COUNTY CLERK ON MAR. 27, 2001 1230 TRAVELER STREET
AS MAP NO. 10596 SOUTHOLD, N.Y. 11971 12-21, 11