HomeMy WebLinkAboutJeselohn/Dubois ELIZABETH A. NEVILLE
TOWN CLERK
REGPSTi:k~R OF VITAL STATISTICS
Ar~kRRL~GE OFFICER
KECOKDS IViANAGE%~ENT OFFICER
FREEDOIV~ OF INFORI~f~ION OFFICER
" JUL 2 2. '.:, i!
TO;., -' ::;. :~SbutholctT~wnBuildingDepartment
FROM: Linda J. Cooper, Southold Town Clerk's Office
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor~kfork.net
DATED: 3uly 21, 2004
Transmitted herewith is a copy of application No, 3351 for a Cesspool/Septic Tank Construction
Perrrdt submitted by:
Paul Jeselsohn & Francis DuBois
Please review the apptication 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 $. Cooper
I have reviewed the application and location map of the project cited above and make the folloxving
recommendations: ~
APPROVE
DISAPPROVE
Comments:
Da~ed o' . ~ .
~ OF~'~CE OF THE. ToWN ci~1(
' ~ Town of Southold .... '
Judi~l~ T. Terry, Town Clerk
ToW~ Hall, 53095 Main Road
P. O. Box I179
Southold, New York 1i97J
Telephone
[516) 765~ 1801
A ppli'~:ati0n No,
$10,00 - Residential
$25,0§ - Nori-Residential
Town OF SOUTHOLD
$OUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
fo r
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No,
Fee $
OWNER NAME: .~,~.,~,
OWNER MAILING ADDRESS;
F vc(3
OWNER PROPERTY ADDRESS: ~ ./~_~1~ .~'~(.,,'~., d~E-~pD~.T
OWNER TELEPHONE NUMBER:
TAX MAP NO.:
CROSS STREET:
TYPE OF SYSTEM:
Section /-1~ .Block oq Lot
Septic Tank . V/ "' New. V/ Existing.
Cesspool New Existing.
Residential (/~ Non-Residential
LOCATION MAP:
Must be attached hereto before permit may be issued.
[Locate building and system; give north arrow and feet
of distance, appi-oximateJy, to building and closest i-oad.)
Tqwn Clerk's Office
~p~)licant