HomeMy WebLinkAboutPetikas EEIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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) 765-1500
southoldtown.northfork.net
TO:
FROM:
DATED: November 4, 2004
Transmitted herewith is a copy of application No.
Permit submitted by:
Nick Petikas
Southold Town Building Department
Linda J. Cooper, Southold Town Clerk's Office
3393 for a Cesspool/Septic Tank Construction
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 application and location map of the project cited above and make the following
recommendations: ~
APPROVE
DISAPPROVE
Comments:
Signature
Dated
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 (631) 765-6145
Telephone (631) 765-1800
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. ~
Permit No.
Applicant Name
Applicant Mailing Address
S~tic T~ ~ or Cesspool '
B~cf Desc~ption of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: AY! C(~
Owner Mailing Address:
Owner Property Address:
676 s" cg. f
Name and phone nurnber of contact person P")IC/~
Tax Map No: /OOO Section~'~ 35 Block
Y It'7 C
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION.
NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALT~[,DEPARTMENT APPROVAL
'- Signatu{e of Applicant - Date
Received by~~ ~/~/~'~
SUl~'v~'r' OF PP-..,.OPtEP-.."'I"'f
~ITt)ATE~ ~I~f=FNPO~T
TOI~N, .5OtYFt4OLD
N
JOHN C. EHLERS SURVEYOR
P~IVEP~HEAD, N.Y, 11901
369-8288 Fax 369-8287 REFZHp ser~er\d~'ROS\04-189.pro