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ELIZABETH A.NEVILLE �h`Z` JP/
� Gym Town Hall, 53095 Main Road
TOWN CLERK o= 1 P.O. Box 1179
• •
ti Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � Fax Fax (516) 765-1823
MARRIAGE OFFICER •
RECORDS MANAGEMENT OFFICER \t* Are #010
Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER .% a
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1881 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : DONALD L. BERGEN
Address 1 : 19105 MAIN ROAD
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 BERGEN, DONALD L. AND MARY
Mailing Address 1 P. O. BOX 1198
City St Zip MATTITUCK NY 11952
Property Address 1 19105 MAIN ROAD
City St Zip MATTITUCK NY 11952
Tax Map No. section 108.00 block 4 lot 5.004
Cross Street ELIJAH'S LANE
Building Permit Number Cross Reference:
Issue Date: 6/08/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE $�`1 .y N Town Hall, 53095 Main Road
1 Z P.O. Box 1179
TOWN CLERK ;
y
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS $ Fax (516) 765-1823
MARRIAGE OFFICER ` '# 1
RECORDS MANAGEMENT OFFICER �49� 0'11 Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED : June 4, 1998
Transmitted herewith is a copy of application No. 1955 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Donald Bergen (work by Ray Nine)
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.
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the folio 'ng recommendation:
APPROVE -
DISAPPROVE -
COMMENTS : Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
'gnat re
(; 'S1gtl"
Date
4
'
OFFICE OF THE TOWN CLEitK 1
1. f o��r
TOWN OF SOUTHOLD ,,�Q� ,1'4. Application No./ 9c-S----
ELIZABETH A.NEVILLE,TOWN CLERK ' 1st
P.O.BOX 1179 b."- Z Construction
SOUTHOLD,NEW YORK 11971
O : Alteration
f� r l
Telephone X040 iorei $10.00 - Residential
(516) 765-1801 - O1 4',,,' $25.00 -Non-Residential
-,,s �
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE SN € L', ( 998
APPLICANT NAME: ,VON it L1) 1. - 6 L Rc E,i
APPLICANT ADDRESS: 19/0c S ro fq /N Rb gi.0.
faq-rTITI)ck , /'11. 1/4' .I/ 9SL
SEPTIC CESSPOOL X
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
N.�- fyr,! �...-g , -. 4- c.-0-0n. ..
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: P 4I A-1-0 it-- ni ada e R RG e-A/
OWNER MAILING ADDRESS: P.D. 66% wig
iii -4-7-1 i Tv
OWNER PROPERTY ADDRESS: / 9/o c Yl, ,q,, ,ti i4,0
n14-r-T roc
TELEPHONE NUMBER OF CONTACT PERSON: j g— 16 a7 - 47 2 v02t/
TAX MAP NO. : Section / 0 Block if Lot 5-• '/
CROSS STREET: E.4irit .f S L/fiv•''-
BUILDING PERMIT NUMBER CROSS REFERENCE:
, 16276--h--d-""e" ''' '': 11-17-''.--
Signature of Applicant
RECEIVED BY: • (A)/(.)-/(A
/ / own Clerk's Office
DATE: Lo
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