HomeMy WebLinkAboutCiampa, Doug & EllenELIZABETH A. NEVILLE, MMC
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS OF MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, NewYork 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: August 3,2011
RE: Cesspool Construction Application
AUG - 4 7011
BLDG. DEPT.
Transmitted herewith is a copy of application No. 4029 for a Cesspool/Septic Tank Construction
Permit submitted by:
Thomas C. Samuels for Doug & Ellen Cjampa
Please review the application and location map and advise if this office may issue thc permit.
Please complete the form below and return it to me. Thank you.
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE /
DISAPPROVE
Comments: Final approval required from the Suffolk County Health Department
Signature
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTI~R 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
southoldtown.northfork.net
OFFICE OF TI-IE TOVgN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10__v or Non-Residential ~ $25 __ Application No. __-I '
Permit No.
Applicant Name
Applicant Mailing Address
Septic Tank v~ or Cesspool
Bri~ Description 9,fProposed Construction or Alteration
Location of Proposed Construction/Alteration:
0wner of Property: 4~>g4~ ~ ~--~[~/4
Owner Mailing Address: ~- o,9~tl ~/e/4
Owner eroperty Address: ,'V,d'.
Name and phone number of c0ntact person ."~o ,~ ._.~ t4~./g. ~ t/,~' "7',~ ~
Tax Map No: Section ~ J Block
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature f Applicant Date
Received by:
SEPTIC PROFILE RESIDENCE
(N.T.S.)
NEIC: ~,,..,~IN~
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m.,. FoR AmOV. L O. CO.SmCT,O. ~0. A
APPROVED
I
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BO'I r0M OF
WOOD
18
42'56'26" W
SOUND
LINE ALON6
APPARENT HIC~H J~TE-P,
HAR~ OC. TC~L=f~ 2~, :2OIO
S 49'
51.26'
7
SITE PLAN ~
SC--~'~'L-~: 1'--;~-= 40'-~TM
SITE DATA
LOCATION MAP
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LINDA ~CAL~
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JUL ~ 0 2011
BUFF. CO. H~LTH ~RVICES
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