HomeMy WebLinkAboutZappala, Agatina ToWN CLERK
REGISTI~ OF VITAL STATISTICS
I~M~RIAGE OFFICER
RECORDS MAtqAGEMENT OFFICER
FR~EDO~V¥ OF INFOR~L~TION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor thfork.net
TO:
FROM:
.J/[~~ ~ ~'~ OFFICE OF THE TOWN CLERK
ToWN OF SOUTHOLD
Southold Town Building Department
Linda J. Cooper, Southold Town Clerk's Office
DATED: January 12, 2005
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 3421
Permit submitted by:
for a Cesspool/Septic Tank Construction
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: /
APPROVE
DISAPPROVE
Comments:
Signature
Dated
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOi~IATION 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 __
Applicant Narne ~ f~-/~-r i'AJ f) ~ ~)t~ ~1
Applicant Mailing Address /--/~).~] ~-~-~12t'C_.ff-.-'~
Application No. ~c/~/
Permit No.
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: El f~ TJ~r~ "2~ 1~ P ~ ~
Owner Mailing Address: 24~q
Owner Property Address: ,O,ST
'
Name and phone number of contact person
Tax Map No: Section 3 L)
Block ,~) Lot / "~ I
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received I~y: _.//ta,,~' ,_at~
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