HomeMy WebLinkAboutGreene ElizabethOFFICE OF THE TOWN CLERK
To~vn of Sou[hold
Judith T. Terry, Town Clerk
To~vn Hall, 53095 ~.lain Road
P. O. Box 1179
Southold, New York 11971
(516) 765- 1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Aopli'ca/10n
Con~lrucl~on
Alteration
Residential
Non-Residential
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ .
APPLICANT NAME:
APPLICANT ADDRESS;
SEPTIC ,)( CESSPOOL
~D~CRI~-~(~I'~ OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP:
LOCATION OF PROPOSED CONSTRUC:FION OR ALTERATION:
OWNER OF PROPERTY: ~'~az~l~"tl~ + /~>lZ~u~
OWNER MAILING ADDRESS: '1¢~ ~/ ~
OVINER. PROPERTY ADDRESS: Ml~b~ '~ ~ C,~.~
TELEPHONE NUMBER OF CONTACT PERSON: ~1~
TAX ~A~ NO.: S~dlo. ~ el~d( ~ ~ Lot
CROSS STREET: q~ ~
BUILDING PERMIT NUMBER CROSS REFERENCE:.,
Must be attached hereto before permit may be issued.
SCDH$ Ref, ~ R10-02-0014
TEST HOLE ~ I
Wofer /n Br.
S~1~ Sand SM
39
Br~n Fine ~o~
TEST HOLE
#!
I
SUFFOLK COL;N?:' G~A~T?I~NT OF H~A,..TH
SINGLg FAMILY R~$1D~NC~ ONLY
I em fm~llor with ~e STANDARDS FOR APPROVAL
AND CONSTRUCTION OF SUBSURFACE ~EF/A~E
DISPOSAL SYSTEMS FOR S~GLE FA~ Y ~E~ES
and ~1 ~Me bY the conditions se/ f~lh ~ ~ on
per~ fo consffucl,
The locations of wells end cesspools
shown hereon ore from field observe/ions
end or from dote obldned from others.
COASTAL EROS/ON HAZARD L/NE
COASTAL EROSION HAZARD AREA MAPS
PHOTO NO. 57' - 556 ~ 83
CERTIFIED TO,
ANDREW d. GREENE
COMMONWEAL TH LAND TITLE INSURANCE COMPANY
SURVEY OF PROPERT)
A T PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNYT, NY
~ooo,- 7a- o4 - o5