HomeMy WebLinkAboutSimon, Lorraine TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hat1,,5309§ Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor~hfork.net
TO,,';:' OF ,~
F~OM:
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Building Department
Linda J. Cospcr, Southold Town Clerk's Office
DATED: June 8, 2004
Transmitted h~rewith is a copy of application No. 3333
Permit submitted by:
for a Cesspool/Septic Tank Construction
Lorraine Simon
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 apphcation and location map of thc project cited above and make the following
recommendations: ~
APPROVE
DISAPPROVE
Comments:
Signature
Dated
~ ELIZABETH A. NEVILLE
TOWN CLEI1K
REGISTFJ~R OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MAlqAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER-
Town Hall, 530,95 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southolfl~owu.northfork.ne~
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 __
Applicant Name ~ AO ~-~t 1/V'~
Applicant Mailing Address ~.'~
Application No. ~ ~ ~
Permit No.
Septic Tank v/ or Cesspool ~.. f~ ,
Brief Description of Proposed Construction or Alteration ~r~(.~ ~/',,~.Es
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Own~PropertyAddrcss: /~ ~_~//~t ,~ ~ .
Name'and phone number of contact person
Tax Map No: Section
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
,CONSTRVCTIONSWW¥ HEALTH , pAR APP OVAr
Signature of Applicant . Dare
Received l~y:
'x
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