HomeMy WebLinkAboutBontje ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road
TOWN CLERK - v= P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(631)765-6145
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER - www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Sabrina Born,Southold Town Clerk's Office
DATED: April 22,2019
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4749 for a Cesspool/Septic Tank Construction
Permit submitted by:
Virginia Br Michael I3ontle.
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
Comments: Final approval required from the Suffolk County Health Department
Signature
Dated
ELIZABETH A.NEVI LE Town Hall,53095 Main Road
rs P.O.Box 1179
TOWN CLERK Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(631)765-6145
MARRIAGE OFFICER .(i Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ( , southoldtown.northfork.net
FREEDOM OF INFORMATION OFFICER
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.Ll`�
Permit No.
Applicant Name " -
Applicant Mailing Address %
Septic Tankor Cesspool
Brief Des nption of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: `., f
Owner Mailing Address'
Owner Property Address
Name and phone number of contact person — -'
Tax Map No: Section g r) BlockLot Z
S ='
Cross Street -- _C -�–
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
L)i��r7^oY.� A.
Signature ofApphcant Date
Received by:
POST�y
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SUFFOLK COUNTYDEPARTMENTOFHEALTH SCRVICES
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require a 5ft minimum separation to
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