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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
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~i v,~ ~' ~ ~l OFFICE OF THE TOWN CLERK
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~ ~uthold Town B~g
FROM:
L/nda J. Cooper, Southold To~vn Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3304
Permit submitted by:
Frank J. Orito
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
sou~h01dtown.nor~hfork.net
for a Cesspool/Septic Tank Construction
Please revie~v 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.
~e~se 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:
APPROVE J
DISAPPROVE
Comments: ~
Signature
Dated
~ ELIZABETI-I A. NEVII 5.E
TOWN CLEtlK
i~EGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MA-NAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hal~ 53095 Main Road'
P.O. Box 1179
Southold, New York 11971
Fox (631) ~65-6145
Telephone (631) 765-1800
soutlioldt own.nor thfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10
Applicant Name
Applicant Mailing Address
r Non-Residential @ $25 Application No. -~--~ O
Permit No.
Septic T~ or Cesspool
Brief Description of Pmppsed Consmction or ~teration ~/~ ~
Owner Property Address:
Name and phone number of contact person ,-~",q~.~,e..
Tax Map No: Section ~..~ Block
Cross Street :~d:)rJ/._/~
Location of Proposed Construction/Alteration:
Owner of Property: ~Z~_, c./,
Owner Mailing Address: ~O ~-/5).~z~:/._/_
NOTE: LOCATIO!~ MAP MUST B/g SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVI~Y WITH HF4kLTH DEPARTM~_.NT AI~.PROVAL
· ~ Sign4t'u~e o f App l~c~n5~ - ~te' !
Receivedb'y: ~ //~/~---- ~J .
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