HomeMy WebLinkAboutThorp SC1JTHCLD VIASTEIMTER D SPOSAL PERM T
CPERATI CN PERM T
SEPTI C TANG or CESSPOCL
Cper at i on Per M t W. 4460-R Rosi dent i al X Non-Pesi dent i al
Fee $ 10. 00 New X Exi st i ng
Nacre Cf Ower DCLCRES THCRP
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Mai I i ng Addr ess 1 825 HAYVWkTERS ROOD
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Mi I i ng Address 2
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C1 t y St Zi p C UrCHOQE NY 11935-0000
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Property
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Property Address 1 825 HAYVIATERS RMD
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Property
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Property Address 2
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a t y St Zi p CXJTC HoaE NY 11935-0000
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Ckner Telephone No. 631-377-2627
Tax Map No. sect i on 111. 00 block 4 1 of 2. 001
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Cr oss St r eet VANSTCN RO D
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I ssue Date: 4/03/ 14 B i zabet h A %vi I I e
-------- Sout hol d Town C3 erk
(TOM SEAL)
o 4S13FFO(,�C
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ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
TOWN CLERK 03 Z P.O.Box 1179
REGISTRAR OF VITAL STATISTICSO Southold, New York 11971
MARRIAGE OFFICER y • �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ��l �a0 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
Residential @$10 '. or Non-Residential @$25 Application No. /
Permit No.
Owner Name
Owner Mailing Address
Owner Property Address 62 J
-A6:,d Al
Owner Telephone No. 3/ " 377 — 26 Z?
Tax Map No: Section _ Block _ Lot Z ,
Cross Street �✓/aA Lh UG�JD-
Please check each that applies: New Construction ✓
Alteration to Existing System
Residentialy- 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 b -Z/ /�/
SignAhe of Applicant Date
Received by:
orrice of wwewater Management
' Suffolk County Center
• Riverhead,New York 11901
(631)852.2100
CER•TII+XCATION OF SEWAGE DISPOSAL SYSTEM ABANDONMENT
Health Department Reference Number: , '' Z1 0060
Suffolk Tax Map#-.-Dist:..i 6DO Stact(s), .� Blk(s) s) cJ
r
Project Name or Address:
Subdivision Name&Lot#
Applicant-Name: Glom
.TUBBY CERTIFY THAT:
1. The first septic tankileaching pool,from the foundation,was located and uncovered,AND
2. If liquid sewage was noted therein,was pumped dry by a licensed sewage haulm AND
I Tank/pool was inspected for outlet line to an o4w low pool•,AND-
4, Overflow pool(s) wastwere located, uncovered'and items'#2 and#3:were repeated until,all:parts of
sanitary system were located,AND
S. All'parts of sani�acy system were mmoy or-ftllpd.wJ'.th qle baclr•1J and.ariy.cort�elld:blocle domes
4 M M
collapsed.
I also cettify that the sanitary system abandotiedconsieW.ctf:
Fast tank/pool --CJext diamdter feet deep OPrecast,block. (:):other-
f
mrst overflow podl"ieet dideep( )precast 4001ock ( )other
Next overflow pool_—Joet diameter feet dere( )precast t )ttlovk( )other
—
Next overflow pool----f t diameter foot deep( )precast-(•)blo*( )other
Company which pumped out sanitary system if differtnnt from certifying company:
Name of Company:
Address:
Consumer Affairs License Number.
Contractor Signature: ate •
Print Name(Com any: C 4 Qne
Address: 0 v cQ
Consumer Affairs License Number. -31
This certlficatlon Fhall not be used in lieu of inspections required by personnel of thebei partment
andan ►he.duplicated on company letterhead,provided ft•t3ofitains the aboie informad0n:
WWM-080 (Rev. 12/01)
T.K.F. Excavating & Demolition
P.Q. Box 27
Westhampton Beach, NY 11978
(516) 924-6818 `
YL
r
p�
TKF Ucavating&Demolition
P.O.Box 27
Westhampton Beach,NY 11978
Phone:(631)878-2700/Fax:(631)653-7430
CERTIFICATION OF S WAGE DISPOSAL SYSTEM BY INSTALLER
Health Department Reference Number: (� — 6 6 o
Suffolk Tax Map#Dist. Sect(s). ` Blk(s) Lot--07
Project Name or Address: K )
Subdivision Name&Lot#:
Applicant's Name:
Description of System Installed:
Septic Tank
Volume(gallons):
Shape:OrRectangular( )Cylindrical
Name of Precast Manufacturer..,
Leaching Pools
Number of Pools:
Diameter&Depth;
Name of Precast Manufacturw
Other:
Attach or sketch below the measurements from building corners to the access covers of disposal system.
1
i
�b
1 hereby certify that the subsurface sewage di
s Ik syste;n ve has been installed by me in accordance
with the approval plans and stands the S ol
operational. t of Health Services and is
Installer Signature:
Print Name/Company Date:
•Ph e: 31 8 8- 700
Consumer Affairs License Number:, r