HomeMy WebLinkAboutKrupski ELIZABETH A. NEVILLE MMC a ��°� � ° ° Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
w Southold,New York 11971
REGISTRAR OF VITAL STATISTICS % u� iw Fax(631)765-6145
MARRIAGE OFFICER �� � Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ;u4 �fw www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER d r 41
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED: April 17, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4748 for a Cesspool/Septic Tank Construction
Permit submitted by:
Tom S inuels
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 u _.
Comments:
Signature
Dated
ELIZABETH A.NEVILLE ' " Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER' Fax (631) 765-6145
RECORDS MANAGEMENT OFFICERTelephone (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
Residential @ $10� or Non-Residential @$25 Application No.
/ 79K
Permit No.
Applicant Name
Applicant Mailing Address
Septic Tank or Cesspool
Brief Description of Proposed Construction r Alteration
Location of Proposed Construction/Alteration: _
Owner of Property: Ell ovor`
Owner Mailing Address: – � ." � k1 sib,
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MY.
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Owner Property
Address:�
Name and phone number of contact person owl , " '
Tax Map o:I Section_f..5-.....— lock Lot m
Cross Street 9LV14 0
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NOTE: LOCATION MAP MUST BE SUBM1TTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEYWITH HEALTH DEPARTMENT APPROVAL
Signature 6f Applicant Date
Received by:
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Abandonment t f existing a. sitar tem n ustit"it
comformancle with departmad,requirement Submit
complcted fonm -,m,,,, „m as proof. PROJECT NO:.
1806
DRAWN BY:
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CHECKED BY: TS
DATE:
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Ir'ERa'i n, FopALP- PROM- �� IN a"s"r�UC`NON (,,) . SCALE:
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SHEET TITLE:
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OVERALL
EXPIRES"rHREE YEARS FROM IDATE OF APPROVAL SITE PLAN
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