HomeMy WebLinkAboutAcker, Anna 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
Southotd, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: JAN - ? . .
Southold Town Bmld~ng Department
FROM: Linda ~_. _C~oper, Southold Town Clerk's Office
DATED: January 5, 2005
RE:
Cesspool Construction Application
Transmitted herewith is a copy of application No. 3420
Construction Permit submitted by:
for a Cesspool/Septic Tank
Anna Acker
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and return it to me. Thank you.
I have reviewed the application and location map of the project cited above and make the following
recommendations: j
APPROVE
DISAPPROVE
Comments:
Signature
Dated [ /
ELIZABETH A. NEVII,T,I~,
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOI~IATION OFFICER
Residential @ $10
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
__ or Non-Residential @ $25
Applicant Name ~]~
Applicant Mailing Address
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Septic Tank or Cesspool /
Brief Description of Proposed Constmcti~/n or Alteration
Application No~C/~ O
Permit No.
Location of Proposed Construction/Alteration:
Owner of Property: ~' ~ ~c~. ~ c.~ e~
Owner Mailing Address: t°, o. F~ × ¢~n_c]
Owner Property Ad&ess: ~S ~ P ~*~ e ~
Nme ~d phone nmber of cont~t pe~on ~ m ~
T~ Map No:/o oO Section ~0 Block
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTJ][ DEPARTMENT APPROVAL
Signature of Applicant Date
Received l~y:
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