HomeMy WebLinkAboutCippitelli, Enzo o�SUFFO(,�co
+ ELIZABETH A.NEVILLE ,`1` Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ,� Fax (631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER 'y�jl�l ���� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southlo�ldtowl1n.northfork.net
�I U OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD 10 d04
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10_X or Non-Residential @ $25 _ Application No. f0 c_3
Permit No.
Applicant Name S�cvr.�l2e G
Applicant Mailing Address C O (TAi t L Wo 4 CAxu-
G F.- urs- 6L( <Y. , Q y
Septic Tank_or esspool26--
Brief Description of Proposed Construction or Alteration .r� E'1Ca S w Ct? +1.� bloC1C
t3�ciM061 w'`K ` a dti2 �tivzrFlG1/
Tt�eS p/i7rga" b o 1v SJNk. ��T GYos c uYaY�^� b�caor�nre�w vU4ek l�-j precq c h
Location of Proposed ConAtruction/Allte�ration:
Owner of Property: r_W L �
I7 �na&11 f
Owner Mailing Address: (Qq e r UE Y 6 i c�hf'& �0 f-
Sv An Fc JJ �• \
Owner Property Address: f , q y S � � (S aS
vt j • Llitq*
Name and phone number of contact person
Tax Map No:/� I I Section \Od 0 Block 114 Lot
Cross Street � 6Q'i5w\ f,..-
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
/ I' Signature of Applicant ate
Received by: l Jk'
A `3
Tank �5 a8 �" SS Lt Q S"-
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4436-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ENZO CIPPITELLI — -- -
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Mailing Address 1 64 RIVER HEIGHTS DRIVE
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Mailing Address 2
City St Zip SMITHTOWN NY 11787-0000
-------------------- -- ----------
Property Address 1 57425 COUNTY ROAD 48
Property Address 2
------------------------------
City St Zip GREENPORT NY 11944-0000
-------------------- -- ----------
Owner Telephone No. 516-503-3130
------------
Tax Map No. section 44.00 block 2 lot 4.000
Cross Street ALBERTSON LANE
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Issue Date: 3/26/12Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
�J
ELIZABETH A.NEVILLE co �� Town Hall, 53095 Main Road
TOWN CLERK � P.O. Box 1179
REGISTRAR OF VITAL STATISTICSO Southold, New York 11971
MARRIAGE OFFICER • O�'T Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone�►� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @ $25 Application No.
Permit No.
Owner Name
Owner Mailing Address
►- Ur,r� , --'•' 11'78 7
Owner Property Address
Owner Telephone No. �� 3��
Tax Map No: Section Block Lot
Cross Street � �� Lp,h 9
Please check each that applies: New Construction `
Alteration to Existing System
Residential. z' Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Signature of App icant ate
-Received by:
� " `r
Wyk o St •-
UnaMorized alteration or addition
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