HomeMy WebLinkAboutUtz, Susan CFOL
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JUDITH T.TERRYyet Town Hall, 53095 Main Road
TOWN CLERK ; y = P.O. Box 1179
^/ �1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 0��� Fax (516) 765-1823
MARRIAGE OFFICER yif'
RECORDS MANAGEMENT OFFICER • ( * `�►0,1 Telephone (516) 765-1800
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. 1460 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : SUSAN VAIL PARK UTZ
Address 1 : P. O. BOX 166
City St Zip ORIENT NY 11957
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-95-0090
Name Of Owner UTZ, SUSAN VAIL PARK
Mailing Address 1 P. O. BOX 166
City St Zip ORIENT NY 11957
Property Address 1 295 YOUNG'S ROAD
City St Zip ORIENT NY 11957
Tax Map No. section 18.00 block 1 lot 12.000
Cross Street ROUTE 25
Building Permit Number Cross Reference:
Issue Date: 4/18196 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY o ,fit % Town Hall, 53095 Main Road
TOWN CLERKH Z P.O.Box 1179
�O % Southold,New York 11971
REGISTRAR OF VITAL STATISTICSl'4‘44;
Fax(516)765-1823
MARRIAGE OFFICER y� O� 1/
RECORDS MANAGEMENT OFFICER W.( lig *sell Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER .��„ ���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD ,1I .,1,
A1-11
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TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office "' 118
DATED: April 10, 1996 00 ,
Transmitted herewith is a copy of application No. 1520 for a Cesspool/
Septic Tank Construction Permit submitted by:
Sue Utz .
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/1-4.---/Le,
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE 1
DISAPPROVE
Comments: 9 .rif2.1 (-5d776 *I/,e 1 -- 9.3-e, Vic=;
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Signature ,;•
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Dated
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OFFICE Of THE TOWN CLERK ,�,,•' "°
Town of Southold 6,''N.+c�UFWit !, Application No. /607L"In F
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road . . . Construction
P. O. Box 1179 " Alteration
Southold, New York 11971 R:`'� ;` /
Telephone " ;," `.. �' '`" �s $10.00 - Residential t/
(516) 765-1801 =- 1 *� ;, •' $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 I/ I 117 q{D
, APPLICANT NAME: 6G-61(+0 V AI I-- PARK W1 "
APPLICANT ADDRESS: Yuxig 5 s , Ort -rK 1 (iQy I �'1
J
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION Nip )
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LOCATION` MAP: • Must be attached hereto before permit may be issued.
LOCATION OF PRG 'OSED CONSTRUCTION OR ALTERATION:
'a OWNER OF PROPERTY: 0-10 1Ia I VC- X"( �k'� "
OWNER MAILING ADDRESS: Pt`(7, I (, ) On PAAA1 JJ y LI ci61
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OWNER PROPERTY ADDRESS: Aq j / '� 12, , tgrilP Y 1 .j6�
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TELEPHONE NUMBER OF CONTACT PERSON: ( iLp) a23- t--i c c
TAX MAP NO. : Section Block Lot
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
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Signature of Ap #cent
RECEIVED BY:
Town Clerk's Office •
DATE:
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1' SUFFOLK CO. HEALTH DEPT. APPROVAL
H. S. NO.
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r ' E Wr UA oP APPROVAt Y
MAP _ QF. : ;.
juI ....f*,..,,,:.,,;;----,.,.., STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE DISPOSAL
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, \ 1`;, 1 ": '' , SYSTEMS FOR THIS RESIDENCE ' WILL ` `
fes' CONFORM TO THE STANDARDS OF THE
SUFFOLK CO. DEPT. OF HEALTH SERVICE
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7.0,y41,\,, Off' ,. uTHQ ...0 1 p,4,,,, ., :,,, SUFFOLK COUNTY DEPT. OF HEALTH
/.__..__ SERVICES — FOR PP VAL FO.R
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SUFFOLK CO- TAX MAP DEStGNAT,ION•
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i.. OWNERS ADDRESS: -
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P.Q.166
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SILTY LOAM Copies of this survey map not beattnQ
�` the land surveyor's Inked sealer
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to be a valid true copy.
SILTY SfSvL)
'j Guarantees indicated horoon shelf run
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is p . and on his behalf to the
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