HomeMy WebLinkAboutOrlick, Paul · ELIZABETH A. NEVILLE
ToWN CLERK
REG[STtLkR OF VITAL STATISTICS
I~[ARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOR~[ATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax ~631) 765-6145
Telephone (631) 765-1800
southoldtown.nor t h fork.net
OFFICE OF THE ToWN CLERK
TOWN OF SOUTHOLD
TO:
FROM:
DATED: January 4, 2005
Transmitted herewith is a copy of application No.
Permit submitted by:
Southold Town Building Department
Linda J. Cooper, Southold Town Clerk's Office
Paul Orlick
3418 for a Cesspoob'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 issne 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: ~'~"~
Dated
ELIZABETH A. NEVILLE -
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
I~Z-~RRIAGE OFFICER
RECORDS M-a. NAGEMENT OFFICER
FREEDOM OF INFORaM3.TION OFFICER
..Town Ha]l, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northforknet
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
,~ - 5 SOUTHOLD WASTEWATER DISTRICT
APPLICATION
~' ' CONSTRUCTION or ALTERATION PER3,IIT
Residential ~ $10 ~ or Non-Residcntial~$25 ApplicationNo.~
Applic~tMailingAddrcss ,~ ~ Z~f~ ~
Septic V~or Cessp~o~ / -- / ' ~ ~
Brief Description ofProp6sed Con~tmction or Alteration ~{~' ~ ~/~ ~/~ ~
Location of Proposed Cons/trtJction/~lteration: ,
Owner of Property:. ff//~g4 [ (~P)[ C/
O~er Mailing Address:_ .5 C; .~ ~ ~' C ~
,~
O~erPrope~Ad&ess: /.~ 0 ~ //eC~ 5f"~
Nam~ ~d phone n~b~r ot con~c/p~rson
No:/X O bt. /
R~eived 5y: ~ Si~a~re of Applic~ Da~e
'SUFIVE'K OF: PROF R'i"K
~ITUATE:
TOI~: ~UTHOLD
~JFFOLK 6OUNTY, NY
.5~JRVE'f'ED O~-IO-O~,
PROPOSED HOU.~E O2-1~-O4
AMENDED O,6-OI-O4-, O-~-Ob-O4-,
O~-11-O4, II-O~-O4, 11-;22-O4
E:,UFFOLK COUNTY TAX :~
1000-5~-2-1
PAUL ORLIC~
o<-.0>///
SUFFOLK COUNTY DEP~L.~.e'~,,vr OF HEALTH SERVICES
PERMIT FOI~ APPrlc~AL (~ CON~TRUCFION PDR A
NOTE~:
O PIPE FOUND
ELEVATION..~ REFERENCE N~VD' 2q
FEMA FLOOD ZONE ANNOTATED FROM FIRM
HAP # ~10,~C.015,4 (9 DTD HAY 4,
COASTAL ER~ION HAZARD LINE ANNOTATED FROM
DEC PHOTO ~ Db-~b-~ SHEET ~ OF 4q
PROPOSE~ PO~OH TO DE CANTILEVERED ~ITH NO
~OPPO~T~ TO BE ~ITHIN I00' OF LONe 15LAN~
//
./
Test Hole
O(~/oq-04
AREA : Ib,22J 5.F. OR O.~"/ ACRE .......... .,o, ..........
'"Z~ ..... ~ 6 EAST M~ S~ET
N.Y.S,
LIC.
NO.
50202
-~'¢~ .......... 369-8288 F~ 369-8287 ~A~p s¢~er[d~ROSX03-128.pm