HomeMy WebLinkAboutTese, JoyceELIZABETH 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
TO:
FROM:
DATED:
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Southold Town Building Department
Carol Hydell, Southold Town Clerk's Office
August 3,2011
BLDG, DEPT.
RE:
Cesspool Construction Application
Transmitted herewith is a copy of application No. 4030
Permit submitted by:
Thomas C. Samuels for Jo¥ce Tese
for a Cesspool/Septic Tank Construction
Please review the application and location map and advise if this office may issue the 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
Dated ~/"~-'~-//
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor thfork.net
Residential ~ $10 ¢ or Non-Residential ~ $25
Applicant Name "/Jif)/'7,,//J_ [ ~
Applicant Mailing Address ~-~3~' d'~4~/'~
Application No. l~O~~
Permit No.
Septic Tank / or Cesspool
Brief D,e, scription of Proposed Cqnstmction or Alteration
Location &Proposed Co~mctioWAlteration:
OwnerM~lingAd~ess: ~ ]~0 E 7~~ ~.
Owner Property Address:
IV /
Name and phone number of contact person
Tax Map No: Section
Cross Street jCf~ ~"'~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Xpplicant Date
Received by:
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