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Home My WebLink AboutKelemen Stephen OFEIC~ O1~ 11ig TOWN Cl~m~ TOWN OF SOUTIIOLD ~?~BEI'H A. NBVILLI]. TOWN CI~I~K P.O. BOX Jl79 $OUTItOLD, NEW YOiU¢ 11971 Telephone (631'} 765-1800 Application No. Construction Alteration $10.00 -Residential $25.00 -Non-Residential TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL CEWED OCT 25 O0'Z Permit No. Fee '$ APPLICANT NAME: DATE PECONIC CESSPOOL APPLICANT ADDRESS: P. 0, BOX 972 MATTITUCK, NEW YORK 11952· SEPTIC CESSPOOL DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: · OWNER OF PROPERTY: OWNER MAILING ADDRESS: OWNER PRopERTY ADDRESS: TELEPHONE NUMBER OV CONTACT PERSON: TAX MAP NO.: Sectiof~ 15 Block <~ Lot 17,% CROSS STREET: BUILDING PERMIT NU,'dBER CROSS REFERENCE: RECEIVED BY: DATE: Signature of ~j~plicant Town c'~erk's Office Stephen Kelemen 77 Main Road Orient ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hail, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.nor thfork.net 2 ?nn COPY FOR YOUR' INFORMAT m t No. OFFICE OF THE TOWN CLERK SOUTBOLO PERMIT CONSTRUCTION OR ALTERATION PERMIT SEPTIC TANK or CESSPOOL 2931 R Residential X Non-Residential Septic X Cesspool Fee $ 10.00 PERMIT ISSUED TO: Name : PECONIC CESSPOOL Address 1: PO BOX 972 City St Zip MATTITUCK NY 11952 Descripton of Proposed Construction or Alteration ADDITION TO EXISTING SYSTEM. APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION INSPECTION REQUIRED. Name Of Owner KELEMEN, STEPHEN Mailing Address I PO BOX 811 City St Zip Property Address I ORIENT NY 11957 77 MAIN ROAD City St Zip Tax Map No. section Cross Street Building Permit Number Cross Reference: ORIENT NY 11948 15.00 block 2 lot 17.004 Issue Date: 10/03/02 Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDO ~M OF INFO ~RMATION OFFiC~ER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southotdtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TO: -;" SoUthold ToTM l)Uilding Department FROM: Linda J. Cooper, Southold Town Clerk's Office DATED: October 25, 2002 Transmitted herewith is a copy of application No. 3051 Permit submitted by: for a Cesspool/Septic Tank ALTERATION Peconic Cesspool for Kelemen Please review the application and location map and advise if the project has received Suffolk County Health Department approval and if this office may issue the permit. Please complete the form below and return it to me. Linda J. Cooper I have reviewed the application and location map of the project cited above and make the following recommendations: b~/ APPROVE DISAPPROVE Comments: Maintain required setbacks from adjacent wells, buildings, property lines and water Bodies. EXCAVATION INSPECTION REQUIRED. Signature Dated