HomeMy WebLinkAboutWilsberg, James ELIZABETI-I A. NEVILLE "'
TOWN CLERK
REGISTtLAR OF VITAL STATISTICS
I~LkRRLkGE OFFICER
RECORDS M3kNAGEA~ENT OFFICER
FREEDOM .OF; INF~LATION OFFICER
Town Hail, 53095 Main Road
P.O. Box 1179
Southold, Ne~v York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southotdtown.nor t hfork.net
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OFFICE OF TI-IE TOWN CLERK
TO~VN OF SOUTItOLD
TO: '---~----~blgTOw mg Department
FROM:
DATED:
Tra~mi2ed herewith is a copy of appli~tion No.
Pe~it sub~2ed by:
James Wilsberg
LindaJ. Cooper, Southold To~m Clerk's Office
June 16, 2004
3334
for a CesspooVSeptic Tank Construction
Please rexdexv the application and location map and advise if the project has received Suffolk Count),
Health Department approval and if this office may issue the pem~it.
Please complete the form beloxv 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
DISAPPROVE
Comments:
Signature
Dated
RI,IZABETH A. NEVILLE
TOWN CLERK
REGISTRAI~ OF VITAL STATISTICS
MARRJ~GE OFFICER
· I~CORDS MANAGEMENT OFFICEK
FREEDOM 01~ INFORMATION O~'v'ICER
Town Hail, 53095 Main Road
P.O. Box 1179
Sou~hold, New York 11971
Fax (631) 765-6145
T~lephone (631) 765-1800
s ou~ho Idtown.norflffork-ne~
OFFICE OF ~ TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION'PER31IT
CESSPOOL or SEPTIC TANK
Residential ~ $10 d or Non-Residential ~ $25 __
Application
Permit No.
Location of Proposed Construction/Alteration_'
Owner of Property:
Owner Maihng Address:
Owner Property Address: ~:} o.I i ~ .
Name and phone number of contact person ~1"~.,~ J
Tax Map No: Section c] c~ Block
Cross Street Eo,~+ Sicl~ I~V~_ ·
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Received l~y: ~~
c./alo'H
Date