HomeMy WebLinkAboutJacobs, Peter ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS I~LANAGEMENT OFFICER
FREEDOM OF INFOR~IATION OFFICER
TO:
..
FROM:
(~FFICE OF THE TOWN CLERK
~.~ ,~;-;f) ~ TOWN OF SOUTHOLD
,:~ t~,
., Southol .d_ Towni~ui~' g Department
~mda J. Cooper, Southold To~ Clerk's Office
Town Hail, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.north fork.net
DATED: February 3, 2005
Transmitted herewith is a copy of application No. 3432
Permit submitted by:
for a Cesspool/Septic Tank Construction
Peter & Mary Jacobs
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
Signature
Dated
ELIZABETH A. NEVTT.T.E
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRL~GE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF LT~FORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Rex 1179
S~utheld, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtowmnerthfork.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 Name
Application No. ~{ ~
Permit No.
Applicant Mailing Address f-O, I~c>?. (~l~ ~_o~sJc ~'-I.C~C(Ov~:K}_~ I~c~l
Septic Tank or Cesspool v/
Brief Description of Proposed Construction or Alteration
Location
Owner of Property:
Owner Mailing Address:
Owner Property Address: q M f)
Name and phone number of contact person tge~-~( e ~t ~r,.~ ,_'C'ac~kl5
~ Tax Map No: Section ~ Block "~:~-- Lot
Cross Street ~ C>O CD ~ ~
NOTE: LOCATION ~ MUST BE SUB~TTED ~T~ ~PLICATION. ~W
CONSTRUCTION ~Q~S SURLY ~T~ ~E~T~ DEP~T~NT ~PROV~
Date
Receiv~ ~y
SURVtE¥ OF= LOT 24
biAP OF: I"IARION I"IANOW.
Fl! ~ NAP. OH I~, IqS~ FII F No..20:D,5
51TUATE: EAST 1,'lAP. ION
TOI, flN-, EX2UT'HO! ~
5b~T, OLK ~T'f', N'r'
.GURVE'f'EP OD-O1~2OO4
AlViENDEO 07-0,5-2004, Oq-2q-2OO4
?flJFFOLK COON"Cf TAX #
I000 - 08 - 2 - I0
T~k I~x~ce
~New Yc~
N
W ,+E :1
S
NOTES:
· STAKE FOUND
AREA = IO,OOO SF OR 0.2~ ACRE5
S.C.[~.H.S. No.RIO-OI-OOE~I
F:'ROF'ERT¥ LIES IN ZONIN~ DISTRICT R-,40
AREA OF PROPOSED' HOUSE EXOLU[~IN~ F'ORCH IS I,qEq S.F.
ELEVATIONS SHO.~N REFERENCE SUFFOLK
COUNTY' TOPOgRAPHIC, AL h4AF~.
~APHIC ~CALF= I"= 20'
13'
DATE '
APPROVED
PARTHENT OF HEALTH SERVICES
OF
JOHN C. EHLERS LAND SURVEYOR
6 EAST MAIN STREET N.Y.S. LIC. NO. 50202
RIVERHEAD, N.Y. 11901 REF.\~Ip server\a%PROS\01-125A.pro
369-8288 Fax 369-8287