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II' 0004
ELIZABETH A.NEVILLE,MMC ����y4'. : . y OGS Town Hall,53095 Main Road
TOWN CLERK ® P.O.Box 1179
W ` 2 ; Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ; 4 'ys � Fax Fax(631)765-6145
MARRIAGE OFFICER _ of
„O." Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ®.l '►," www.southoldtownn .••
FREEDOM OF INFORMATION OFFICER
- ''
OFFICE OF THE TOWN CLERK \.;1 , ; �1t-; i
TO: Southold Town Building Department
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: September 24,2015
Transmitted herewith is a copy of application No. 4341 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
John Hocker of Latham Sand& Gravel,Inc. for Vincent&Nida Lee
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. Thank you
* * * _ * * * * * *
I have reviewed the application and loc tion map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Maintain required setbacks from adjacent wells,buildings,property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED. .
Signature
e/
Dated
/,••dill„��_
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ELIZABETH A.NEVILLE �,'I`` �j► Town Hall, 53095 Main Road
TOWN CLERK ; p ; P.O.Box 1179
` Southold New York 11971
REGISTRAR OF VITAL STATISTICS : err I
MARRIAGE OFFIOMt ( `W Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = OI 0.oil Telephone(631)765-1800
FREEDOM OF INFORMATION OFFICER _ *
a' southoldtownnorthfork.net
OFFICE OF THE TOWN CLERK
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 X or Non-Residential @$25 Application No. y 3141
Permit No.
Applicant Name Jhri h cL r, 4Rrr .5t=inci-6rA kR
Applicant Mailing Address 1 R 60
��cc�nr c 195g
Septic TankXor Cesspool
Brief Description oklredConstructionor Alteration ee, a r
/6cft-tiolTv L ( i HOA(7- i2
QUI "PS •'Ci �CR�Ki
Location of Proposed Construction/Alteration:
Owner of Property: 11?fCQrrl--r- Acid tee,
Owner Mailing Address: /4. t42 fn n e34rap-1-. Of), 3.
` (cj Lju ),rr fly 11931
Owner Property Address: 440
OL! (Crii
Name and phone number of contact person
Tax Map No: /O CO Section iD P- Block 3 Lot /6
Cross Street J(fl Ope
NOTE: LOCATION'MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DDEPARTMENT APPROVAL
745—
it Signature of App cant Date
Received by: I r
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