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ELIZABETH A. NEVILLE, MMC 4'^��°` � "`'av Town Hall,53095 Main Road
TOWN CLERK ��" �wp P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(631)765-6145
MARRIAGE OFFICER im,,, � Y Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ���� �� �� www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER w „w
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED May 15, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4753 for a Cesspool/Septic Tank Construction
Permit submitted by:
Jeffrey Blum
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:
Signature
Dated
OF Fol
ELIZABETH A. NEVILLE Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
C4 Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS +
MARRIAGE OFFICER ° Fax(631) 765-6145
RECORDS MANAGEMENT OFFICERfr Telephone (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. .....q 763.
Permit No.
pp =— '
A licant NameW'� �� G� � ��r
Applicant Mailing Address �L6 �
Septic Tank r Cesspool
Brief Description of Proposed �oaastr�rctiµon or Alteration� V IT . v
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Location of Proposed Construction/Alteration:
Owner of Property: �.
l " y.
aw
Owner Mailing Address: ..... .. mmmmmmIT
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Owner Property Address:
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Name and phone number of con :...
tact person
Tax Map No: Section - Block Lot
Cross Street_ l �t � C61L,,,'
�...�. mow......__.. - _........
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY ITI °IIEALTH DEPARTMENT APPROVAL
Sigrr.aturc of Applicant Date
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Received by: -
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