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Town Hall 53095 Main Road
ELIZABETH A. NEVILLE,MMC Town ,
�
C P.O. Box 1179
TOWN CLERK
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �� ���) Fax(631)765-6145
MARRIAGE OFFICER �
aP ��
4 � D" :��d� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ` www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER , r
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED: December 6, 2019
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4820 for a Cesspool/Septic Tank Construction
Permit submitted by:
MaEy Bush
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. 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 , or Non-Residential @ $25 Application No. g��
Permit No.
Applicant Name � �.. ..._.�.__ ke
...e �� .�" ..._��, � ......�.
Applicant Mailing Addl-es �, �' �" �_ .. ,�
Septic Tank_yor Cesspool
p .......
ol
Brief � 1 Construction or Alteration mm_ �_..........�.-.....�,.
sci��t�o�� o � � d,"� s
Proposed
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lm
Location of Proposed Construction/Alteration:
Owner of Property: � � ... ... a.� w .�� .. ...m _"�I_ � ,. ��" ns1
Owner Mailing Address:..— a
Owner Property Address: v
� E4_
Name and phone number of contact person r
�l, 01
(D
Tax Map No: Section t L4 �..................,_�Block_.......�.... ........................_ Lot -
Cross Street_ww- � -ter
NOTE. LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
sil'lature o1 Applicant
.. Date
Received by: —T"-- -
Boulevard PlanninE,P.C.
Construction Consultants
> 516-8.17-2001
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SANITARY AS-BUILT
PERMIT R10-19-0086
TO
225 Pine Street
6
Mattitue(c,NY
DISTRICT 1000
SECTION 141
\ BLOCK I
Ott LOT 36.3
REVISIONS: DATE:
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\ H.. ,, T. John E.Stumpf. P.C.
\
ARCHITECTS-ENGLNEERS
LANNURVEYORS-
.. �,\G '725 F—ddin A
3-d— ve.
it i� -d—City,NY 11530
�� Telephone Pax
516 87-0400 516-746-8622
F�
\ IAO\- 631-734-2011 516-538-4090
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DIMENSION TABLE ss sr<o e
STA.x FOR CUHS t h 3 AS&GS T P-O A-
SUFFOLK COUNTY DEPAlITNZNT D ,HEAL:j H SE V!Qt_ � EEEt ARcyf
SANITARY AS-BUILT -_, a _. . . , , -. _ .;. s �w .srU ,
TOTAL LOT AREA 24,998 S-
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