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ELIZABETH A. NEVILLE,MMC � x4 �*,. Town Hall,53095 Main Road
TOWN CLERK P.O. Box 1179
► �� 1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1,4'46 <V*,1 Fax(631)765-6145
MARRIAGE OFFICER .� tehw� � ,•# Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER "•. '.� ' www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: February 4, 2016
Transmitted herewith is a copy of application No. 4371 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Susan & Tom Llewellyn
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 location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
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Comments: Maintain required setbacks from adjacent wells, buildings, property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
Signature
Dated
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ELIZABETH A. NEVILLE Town Hall, 53095 Main Road
���°� - � .
TOWN CLERK P.O. Box 1179
4 va 1 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS r
MARRIAGE OFFICER "..1.1 '” 0 Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER q454f ®s o° Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER =°I 4;111° southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
_
Residential @ $10 'or Non Residential @ $25 Application No. 37
Permit No.
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Applicant Name ��-��%'ZA-'`'c' �,5fi".2 0 ti - ---
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Applicant Mailing Address 'Vc=-' 6&----"---- /f`-' 7 (/- �e'c `fit 4/Y
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Septic Tank or Cesspool (/ ,y, Wiz- -�``
Brief Des ription of Prp Construction or Alteration
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Location of Proposed Construction/Alteration: i
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Owner of Property: � 5 �'�/G LGAt 't�` ' �c'L''-r
Owner Mailing Address: 0i ' - i .' -i7
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Owner Property Address: i 45 '�
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Name and phone number of contact person
Tax Map No: Section s Block . Lot I
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALT PE 'ARTMENT APPROVAL
Signature of Ap R can Date
Received by: 0.-/1
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