HomeMy WebLinkAboutJaycox Freda ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
......... MARRIAGE OFFICER ' ·
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (63~).76~-614~5
Telephone (631) 765-180b
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 ~ $25 __
Application No. 3 ~"~/3
Permit No.
Applicant Name ~._'To,¥,o ~--')-t'f'~.,t~o,4.)
Applicant Mailing Address / ~ ~e~ ~
Septic Ta~ ~or Cesspool ~
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: ~ ~,~A ~-,~ ~'~,~,
Owner Mailing Address: ~c2,q~ ~tfZdt~.-od ~-
Owner Prope~y Address: / ~ ~ -- ~- ~ --/~
Name and phone number of contact person ~o~~mo ~O$-~l&
Tax Map No: Section ~/~ Block ~ Lot /~
Cross Street ~ ~'X~ ~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUI~S SU~~TH nEe~TMENT APPROVAL
~f Applicant Date
Received by: _~~
TIAIO
NOR'I~ SF.~ DPdV~
FOR A
TEST
HOLE
I
JOHN Co EHLER';5,
6 EAST MAIN STREET
RIVERHEAD, NY. 11901
369-8288 Fax 369 8287 REF
5UP-.~ OI= LOT
MAP OF: ORIENT BT' THE .SEA, -SEC, TION THO
FII FD OCTC~R 18, IqSI FILE No.
SITUATE: ORIENT POINT
TOk~: 50UTHOLD
SUFFOLK ¢_..,OON'l'h", N'r'
SURVEY'KE/2 05-1F~-02
.SUFFOLK COUNTY' TAX ~
1000-15-6-10
CERI'~b'~F_,~ TO:
~ R. ~'ay~ox
Safe Harb~- Tide ~, ~.
T~
O~-Iq O~
NOT~S:
STAK;E FOUN[2
AREA = 23,45~ SF OR 0.54 ACRES
Title ¢ SAH220Fo25
®RAPHIC SCALE
PI:'RMIT FOR APPROVAL OF CONSTRUCTION FOR A
SINGLE FAMILY RESIDENC~ ONLY