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JUDITH T.TERRY � � k Town Hall, 53095 Main Road
TOWN CLERKt y i i P.O. Box 1179
4 Southold, New York 11971
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REGISTRAR OF VITAL STATISTICS � O aO�l',1 Fax (516) 765-1823
MARRIAGE OFFICER :�
RECORDS MANAGEMENT OFFICER l 41, ' ,0 Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER •-azcz
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 78 N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
ADDITION OF CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM WELLS,
BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION INSPECTION
REQUIRED.
Name Of Owner BURRIESCI, ANTHONY
Mailing Address 1 NORTH FORK GRILL
9650 MAIN ROAD
City St Zip MATTITUCK NY 11952
Property Address 1 9650 MAIN ROAD
NORTH FORK GRILL
City St Zip MATTITUCK NY 11952
Tax Map No. section 14.00 block 1 lot 1 .000
Cross Street
Building Permit Number Cross Reference:
Issue Date: 9/10/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OAP
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JUDITH T.TERRY t _ 'yam Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
0 ,� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS y� O�41'� Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER Oj � le. 06 Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER - , ,•i'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED: September 8, 1997
Transmitted herewith is a copy of application No. 1500 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic cesspool for Anthony Burriesci
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 this office.
Thank you.
Li da J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the follow in recommendation:
APPROVE -
DISAPPROVE -
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
S .•nature
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Date
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OFFICE OF THE TOWN CLERK
Town of SoutholdFFQtxev = Application No./ C-O d
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road !� - Construction Li
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P. 0. Box 1179 m
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Southold, New York 11971 ;� W ; Alteration _
Telephone =",`� ��`�' es den is `
(516) 765-1801 - 41 $25.00 - Non-Residential '
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ /10- ----- .
DATE u/f7
APPLICANT NAME:
APPLICANT ADDRESS:_ Q jo./-
SEPTIC CESSPOOL I/
DESCRIPTIOPR•POSED •NST • UCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION R ALTERATION : .
OWNER OF PROPERTY -`
OWNER MAILING ADDRESS: 9 5 _ -4.,d
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: (.71 lee--96 sIF
TAX MAP NO. : Section : Block I Lot /
CROSS STREET: 1J
BUILDING PERMIT NUMBER CROSS REFERENCE:
yeel(44..../Z / / \/,,
Signature of Applica'
RECEIVED BY : ,
TWAWs Office �f
DATE:
SEP 8 1997
Southold Town Clerk
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