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" ' Town Hall,53095 Main Road
ELIZABETH A.NEVILLE,MMC �� ^��"' Pf v t
TOWN CLERK „
P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ��� 0t J All
7 Fax(631)765-6145
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ' www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER ..a.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Southold Town Clerk's Office
DATED: January 6, 2021
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4931 for a Cesspool/Septic Tank Construction
Permit submitted by:
Brittny and Eric Knight
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 µ P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER Fax(631) 765-6145
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
PERMIT
CESSPOOL or SEPTIC TANK
Residential @$1 X" or Non-Residential @ $25 Application No. r�I
Permit No.
Owner Name ` (.. o
Owner Mailing Address L_ a
M.
Owner Property Address 's a
_.WWW
Owner Telephone No. .,... ..u)' k) 'm ....
Tax Map No: Section ` Block Lot
Cross Street w ,
Please check each that applies: New Construction
Alteration to Existing System
Residential x Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
o 2 1
Signature of Appli t �te"
Received by: f-I--
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/06/21 Receipt#: 277156
Quantity Transactions Reference Subtotal
Septic Permit-Construct- Resid. 4931 $10.
00
. .. Total Paid, $10.00
Notes: 126.-11-7
Payment Type Amount Paid By
CK#9875 $10.00 G.B. Construction and
Development, Inc.
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Knight, Brittny & Eric
217 Sands Point Rd
Sands Point, NY 11050
Clerk ID: JENNIFER internal ID:4931
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