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ELIZABETH A.NEVILLE,MMC 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
` - Fax
1)765-6145
5-1800
RECORDS MANAGEMENT OFFICER wwwsoutholdtownny.gov
FREEDOM OF INFORMATION OFFICER -- v
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Sabrina Born,Southold Town Clerk's Office
DATED: September 19,2019
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4787 for a Cesspool/Septic Tank Construction
Permit submitted by:
Jack Norris.
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.NEVILLE 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
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 V or Non-Residential @$25 Application No.
Permit No.
Applicant Nam
Applicant Mailing Address
Septic TankorCesspool
Brief Description of Proposed Construction or Alteration jwt- 51&P77c-
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Location of Proposed Construction/Alteration;
Owner of Property:---��-4c-vc-N)l0tsg��-1
Owner Mailing Address: 4 rev+,A1-rz-b c%ct-ct,,fi
Owner Property Address: (,Y'7-1
Name and phone number of contact person
Tax Map No: 0000 Section 10:r— Block Lot 13
Cross Street
NOTE. LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicar�f t ate
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