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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTI:L-kR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
Southold Tmvn Building Depa~mcnt
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax {631) 765-6145
Telephone ~631) 765-1800
southo]dtown, nort hfork, net
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: April 18, 2005
Transmitted herewith is a cop), of application No. 3460
Permit submitted by:
for a Cesspool/Septic Tank Construction
Sydney & Deborah Dufton
Please reviexv 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 retum it to me.
Linda J. Cooper
[ have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments:
Signature
ELIZABETH A. NEVILLE --
TOWN CLERK
REGISTRAH OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM Ok' INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
· APPLICATION
..T°wn Hall, 53095 Main Roe
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-614:5
Telephone (631) 765-1800
southoldtown.northfor k.nei
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 :,/ or Non-Residential @ $25 __ Application No.
Permit No.
Applicant Name .~,,P~ c ~ ?J ';~¢ [~?' ,:'~ [~3 '~.~'-%
Applicant Mailing AJdress I
Septic Tank I/for Ce~p0o~t
Brief Description of. Proposed Construction or Alteration Q;~f .,:,~¢.,,-,.J ,^ ~¥,.')"7
Location of Proposed Construction/Alteration:
Owner Mailing Address: *O~p'- ~hr~('~ J~.',~.oC~, "~-
Qo ~ ' ' -
Name and phone number ofcontact person '[',~:J~_ .j.'~.,~'rc,'h-
TaxMapNo: Soction~BBck ~_1~ . Lot 75
Cross Street ~¢cr&~cy.~.> L-~.q~_.~ ' '
NOTE: LOCATION MAP MUST BE SUBMITTED WI~d~A~CATION. NEW
CONSTRUCTION R QtaaES StrRV Y wr .,B mALT Or pAx / mNT APPROVAL
· 'a-- o~ Applicant ' '
d
limit of cleorlr~, ~rodln~j
cjrov~cl dlst~'o~nce
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