HomeMy WebLinkAboutLauback ELIZABETH A. NEVILLE, MMC � � �� a� Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
Southold,New York 11971
°REGISTRAR OF VITAL STATISTICS Fax(631)765-6145
MARRIAGE OFFICER � 1 �� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER wry Jud www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED: May 16, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4757 for a Cesspool/Septic Tank Construction
Permit submitted by:
Jeffrey Luback
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
ELIZABETH A. NEVILLETown Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
WSouthold, New York 11971
REGISTRAR,OF VITAL STATISTICS WFax (631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER "� �« 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 m�/or Non-Residential @ $25 Application No. L�
Permit No.
Applicant Namem ...... .
t
Applicant MailingAddress
�.. .... _a
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
p y — r'
Owner of 1�"e�o �.�-t : � ���-
. —
Owner Mailing Address: 010
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Owner Property Address:, �r:,. . . O -
Name and phone number of contact personlyk- 7 .. t,
3 Tax Map No: Section Block� Lot � --
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEAL T I EPA:NI TMENT APPROVAL
igc .tu of Applicant Date
Received by:
SURVEY OF
U -cESSP°° LOT 21
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