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ELIZABETH A.NEVILLE,MMC ��� mf �, Town Hall,53095 Main Road
TOWN CLERK " P.O. Box 1179
k Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 4 w� Fax(631) 765-6145
MARRIAGE OFFICER 0jTelephone(631)765-1800
RECORDS MANAGEMENT OFFICERo �. 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: July 8, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4767 for a Cesspool/Septic Tank
Construction Permit submitted by:
Discount Cesspool and Drain for Robert Kraus
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
1
� �v
ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
P.O. ox 1179
TOWN CLERK k or
New NeYork 11971
REGISTRAR OF VITAL STATISTICS Southold,
(,Ne York 45
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
� � Telephone (631) 7651800
�y � � °
FREEDOM OF INFORMATION OFFICER �. southolto .nortor .net
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1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL r SEPTIC TANK
esi ential@$10 V1 or Non-ResidentialApplication o.
Permit No.
ApplicantName —� w �c_ is LA.
Applicant Mailing Address . _ � ...._ � —` ""�
... _� w _...�... _. _.... ...... _.. . ...._..... .,... .__...—.._�._ j
Se tic Tani . r Cesspoo
n of Proposed Construction or ltNala -.._�
Brief Description
Location of Proposed Construction/Alteration:
Owner Mailing Addres . ,
Owner Property Addi-es
Name and hone number of contact er
p p�,. son im.- '
Tax Map No: Section � Block _...
......_. cis...µ... .... Lot .�. . M.
Cross Street �.�.... p, _ ..._
. ......w .......� � ..�... ..�� .w. �� .w... �.._ .....
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SU EY WITH HEALTH D] PARTME T APPROVAL
iature of Applicant Date
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