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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hail, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
soul holdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
· ''
FROM: kinda J. Cooper, Southold To~vn Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3522
Pemfit submitted by:
for a Cesspool/Septic Tank Construction
Tom Ludlow
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 rethm it to me.
Linda J. Cooper
I bare reviewed the application and location map of the project cited above and make the folloxving
recommendations:
)d~PROVE
DIS?d~PROVE
Comments:
Signature
Dated
ELIZABETH A. NEVH .I .E ~"
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION 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 ~ $1~? or Non-Residential ~ $25 __
Application No.~
Permit No.
Applicant Name '-~
Applicant Mailing Address
Soptic Tank ~r Cesspool
Brief Description of Prooosed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person '
TaxMapNo:lO~o Section ~d~ 5d-~ Block
Cross Street ~Y'C,~I~,~ L ~0',~- .
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
Signature of Applicant Date