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ELIZABETH A.NEVILLE Town Hall, 53095 Mein Road
TOWN CLERK P.O. Box 1179
Southold,New Fork 11971
REGISTRAR,OF VITAL STATISTICS �I�",' Fax 6145
''"r ax(631} 765
MARRIAGE OFFICER Telephone (631) 765-1500
RECORDS MANAGEMENT OFFICER
southoldtown.northfork.net
FREEDOM OF INFORMATION OFFICER �4B
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10, or Non-Residential @$25 Application No.
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Permit No,
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Applicant Nai:��
Applicant Mailing ,ddr�.ss_ : '"
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Brief Description
�tl or Cesspoolsed Construction or 1
on of Proposed ��.��•atiori ...
.
Septic
Location of Proposed Construction/Alteration:
Owner of Property:� 'm .� � Lb. "...... ....
Owner Mailing Address: Laa
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Owner Propertys. a
Name and phone number of contact person, 1 �Bl
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Tax Map No: Section m. _ ..... ...M.Block ....w� � ......._- Lot.....
Cross Street
NOTE: LOCATION MAP MUST BE S J ARTT B WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEYF.1T 11.1 T11 DEPARTMENT APPROVAL
Zo
-lat C 0 )PliCallt Date
Received by:
SHEET �
DAM POND
,� NOTE: LOCATION OF NEW POO
�0041 ` ENCLOSURE FENCE IS BOUND'
BETWEEN NON D15TUR A NCE
L S 6 NON TURF BUFFER
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& 50 �
mo ..
N TURF F'FE
WELL nM 15 FT WIDE
. 'ON DISTURBANCE ZONE
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IZASTIN6 POOL a
TO BE REMOVW r
oring J
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PARKINS N,
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Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 11/16/20 Receipt#: 276339
Quantity Transactions Reference Subtotal
p --...$10.00
...
_.._. 1 .. . Septic Permit Construct- Resld .......,. ... ......... 4913 _ .....�. 10 0 ....
Total Paid: $10.00
Notes:
Payment Type Amount Paid By
Credit Card-Ref# $10.00 Steelman, Nancy
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Steelman, Nancy
25235 Main Road
Cutchogue, NY 11935
Clerk ID: BONNIED Internal ID:4913