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FROM:
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STA'rISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORI~,L~TION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
~uilding Department
Linda J. Cooper, Southold Tmvn Clerk's Office
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
DATED: August 2, 2005
Cesspool Construction Application
Transmitted herewith is a copy of application No. 3495
Permit submitted by:
for a Cesspool/Septic Tank Construction
Christine Rivera for Papadopoulos
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and remm it to me. Thank you.
I bare reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE ~
DISAPPROVE
~.~ - 'x
Comments: ~
Daied ~ '
ELIZABETH A. NEVILLE '.
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAOE OFFICER
RECORDS 1VaANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICEE
.,.,Town Hall, 53095 Main Road
P.O. Box 1179
Southold. New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nort hfork,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
Applicant MailinffAddress
Septic Tank ,-~or Cesspool
Brief Description of Proposed Construction or Alteration
Application No. __
Permit No.
Location of Proposed Construction/Alteration:
Owner of Property: ,~'~
Owner Mailing Address:
Owner Property Address: ..~,o ,.~-'..~- ~-"~
Name and phone number of contact person
Tax Map No: Section /d~oo Block
Cross Street ~,~ ~,
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH ,HE~TILDEPARTMENT APPROVAL
Signature o f. Al~licant Date
Received I~y: , ,~--dJMJI /
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