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JUDITH T.TERRY � _ t\ Town Hall, 53095 Main Road
TOWN CLERK 4 y ' P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS O ���
MARRIAGE OFFICER � i . 1 Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER �/0,( *so.'�� Telephone (516) 765-1800
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FREEDOM OF INFORMATION OFFICER - ��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1674 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : IRENE BARKIN
Address 1 : 5 FARMSTEAD RD.
City St Zip COMMACK NY 11725
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-97-0018
Name Of Owner BARKIN, IRENE
Mailing Address 1 5 FARMSTEAD RD.
City St Zip COMMACK NY 11725
Property Address 1 4040 BAYSHORE ROAD
City St Zip GREENPORT NY 11944
Tax Map No. section 53.00 block 6 lot 27.001
Cross Street ISLANDVIEW LANE
Building Permit Number Cross Reference:
Issue Date: 6/02/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
4119.
MAY 4
cost
tr) TowffrirgLivalfain Road
•j,�0 Obi P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY 1��. 'l � - TELEPHONE
TOWN CLERK `••••..•••••••••
(516) 765-1801
REGISTRAR OF VITAL STATISTIC'S OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: May 13, 1997
Transmitted herewith is a copy of application No. 1745 for a Cesspool/
Septic Tank Construction Permit submitted by:
Irene Barkin
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.
Linda J. Cooper
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE
DISAPPROVE
Comments:
RECEIVED
MAY 30 1997 ignatu
Southold Town Clerk Dated
OFFICE OF THE TOWN CLERK
Town of Southold 40111./(6\
Judith T. Terry, Town Clerk � � 4`: Application No.
Town Hall, 53095 Main Road Construction
P. O. Box 1179
Southold, New York 11971t� +� Alteration
Telephone , ', �Q��/' $10.00 - Residential
(516) 765-1801 �l �, �'�� $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ �
DATE /9/Y (37 .7
APPLICANT NAME: / P---iif/E-
APPLICANT
ADDRESS: Ly : -A - A . i =4/111, AP
.40 - (9'J • . _ f i. �. //7.31—
SEPTIC CESSPOOL Z/
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
ham- ,- 3 Bk_ 'w$
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
OWNER MAILING ADDRESS F4 ,-1l � f2.0
OWNER PROPERTY ADDRESS: (L_te,
02 "� ,&1- /1/ / //qq(74
4'G
TELEPHONE NUMBER OF CONTACT PERSON: .`j �7,
TAX MAP NO. : Section S3 Block 6'6 Lot cL 7, (
CROSS STREET: / 52-4-Vi 1//- 11(// A/V
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applica
RECEIVED BY:
wn Clerk's Office
DATE: 5)/ / 9 '
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DATE APR 28 1 g7 .
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FOR - 41 IUM OF= '.,DROOMS
EXPIRES THREE YEARS FROM DATE OF APPROVAL
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