HomeMy WebLinkAboutSouthold Medical Arts Bldg
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ELIZABETH A. NEVILLE
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
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r":-;" (;. CD" IT, i "~FFICE OF THE TOWN CLERK
. . .:\ TOWN OF SOUTHOLD
DCi I I 2006 '
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'~~utho~:rj}wn B~ilding Department
TO:'
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FROM:
Linda J. Cooper, Southold Town Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3638 for a Cesspool/Septic Tank Construction or
Alteration Permit submitted by:
Scott B, Sheren
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
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I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
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DISAPPROVE
Comments:
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Signature
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Dated I /
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EUZABETH A. NEVILLE ... ~
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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Town Hall, 58095 Main Em
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P.O. Box 1179
Southold, New York 1197J
Fax (681) 765-6145
Telephone (681) 765-1800
sou tholdtown.northfork. ne
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential@$IO_ or Non-Residential @$25 /
Application No!!i.A~
Permit No.
Applicant Name SalT~' flJI t-r;J
Applicant Mailing Address 19 J2wAJt,(c /f.J:CCt. (,J1{ )"Z---
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Septic Tank .,/ or Cesspool v
NJri5.,~crZiPtion;g,rop se~ s otion or Alteration
Location J~POSed Construction! Alteration: I r
Owner of Property: Sti~'Ifw() M..tAllLYL- A(lX'::, 6ut!j,~ yvL.-
OwnerMailingAddress:--Lj TtrIVN(O-s JJta< LL;N ~
uJ€~ T7-1--+t1-t .''tV ).J t: 1
Owner Property Address: ';vR,zr..Lt ~nI '
Name and phone number of contact person St!:OfT B ,J~ I2.t A)
Tax Map No: Section.5 S-' Block 0 ~ Lot
Cross Street g~)J.~~
NOTE: LOCATION MAP MUST BE SUBMl'l"I'ED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURvEY~TH DEPARTMENT APPROVAL
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-- Signature of Applicant Date
Received by: r'~ ~ ")
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NoTE, ELl:vATlONS ARE REF"ERENcED To AN
As5lJM1:D DATUH. EX/STINe ELEvATIONs
ARE SHoWN rnJs 50.0
ALL. SURvey RELATED INF"ORMA TION TAKEN
SURvey PREPARED By -losEPH A. IN$/';$No
LAND SURVEYOR DATED. F'E6~ARY 28, 2006
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HEAL TH DEPARTMENT SEAL
SUffOlk COunty Department of fleallll Services
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