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JUDITH T.TERRY is��
4:9G Town Hall, 53095 Main Road
TOWN CLERK y • P.O. Box 1179
,f Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �1
MARRIAGE OFFICER #* O��1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = Ol Jit *el" Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,•i
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1642 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ROBERT GAMMON
Address 1 : P. O. BOX 1838
City St Zip SOUTHOLD NY 11971
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. #R10-96-63
Name Of Owner LATSON
Mailing Address 1
City St Zip 0000
Property Address 1 R.O.W. OFF YOUNGS AVENUE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 64.00 block 1 lot 14.001
Cross Street ROUTE 25
Building Permit Number Cross Reference:
Issue Date: 4/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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)1.. *. Town Hall, 53095 Main Road
' �1,y0 f P.O. Box 1179
sI1O' 11 �� Southold, New York 11971
JUDITH T.TERRY ��� � .= TELEPHONE
TOWN CLERK
(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: April 7, 1997
Transmitted herewith is a copy of application No. 1712 for a Cesspool/
Septic Tank Construction Permit submitted by:
Robert Gammon •
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
APR 2 2 1997 Si nature 000'Southold Town
1� �.... . Dated
7
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OFFICE OF THE TOWN CLERK """
Town of Southold 'commit*
Judith T. Terry, Town ClerkArr. a Application No.) 77>--
Town Hail, 53095 Main Road Construction
P. 0. Box 1179
Southold, New York 11971 Alteration
Telephone -Residential
(516) 765-1801 _ 411 ,, $25.00 -Non-Residential Non Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE 1-) /7/c I
APPLICANT NAME: Qôej'1*-1-- CZ4VVtGv(C/1
APPLICANT ADDRESS: a T•Wm C .IL [A (Po. Nx%-(c5y
) , \N -r
SEPTIC CESSPOOL
DESCRIPTION OF PROP ED CONSTRUCTION OR ALTERATION
�8W �Lk 4t4a,c( OcVd(14-
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
OWNER MAILING ADDRESS: S
OWNER PROPERTY ADDRESS: S A-km. `C
TELEPHONE NUMBER OF CONTACT PERSON: c----X'S-Sc-60 (
TAX MAP NO. : Section CQ L` Block G t Lot
CROSS STREET: YC.JC)Vl 7 42-- 3 ��
BUILDING PERMIT NUMBER CROSS REFERENCE:
ignaturepplicant
RECEIVED BY:(X'
l/�(9-Cgs
Town Clerks Office
DATE: -
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Y y` .fir V• \Ili .`may `?7. �•�
1`V))
if, �� C we P /o�'�
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v f %� i BY SCD - OTS APPROVED acwe<< \ ,
AR -;
> The locations of wells and cesspools T y�
;:li:\ 'A k) ra showtt hereon ares from field observations .�"" MFl?, `''"
=�.,,r, . 1 4 ! �:�� and apt from dole ob/ained lrom others. ��
. i• ` '�, / , Iamb with the STANDARDS FAR APPROVAL
^1'7r • ' CaSSTfUMON OF SLBSLIWACE SWAGE ANY AL TION OR ADDITION TO THOS SURVEY ISA VIOLA TION I
iyx �'. r i
I ' `•i, SYSTDRS FAR RAZE FAIL Y RESDIOYCES OF SE 7209 OF TIE AEN' YORK STATE EDUCATION LAW • 1i
and ri abide the cond i= set forth l T PER same*
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Su~cIk � permit /o construct
*trek and on the TJgIV 7Po9 StA VD7pN 2 ALL CERTIFTCA�'ONS
HEiEON AWE VAI-0 F THS ACIP AAD comb
THEREOF ONLY F �� ;,� , t8 N;� UC. NO. 49618
+v1,C„ms,.__ "_`�t>° 4 • OR S c .SAS fE]iE SEAL OF THE SLIWEYOR ;VI
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TuRe-
-�- ADDITTONAtLY To cam:cY WITH SAID LAN' T?E TERM 'AL m mai or
P. Q BOX 900 I
• MUST BSE' USED BYWAND AAD ALL SL YOBS UTTLIZINS A cOPY 1230 TRAVELER STREET
OF ANOTHER SY.RVEYpts MAP. 'TDils SUCH AS CTlcp•AIiOt ,
•
OtJIGFIT�TO-DATi'NE NOTN CAIF�iMKE NITF/ 7 E.UM 5� K�: 11971
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