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JUDITH T.TERRY �� �`�� Town Hall, 53095 Main Road
TOWN CLERK y Z P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ;Gy ,��� Fax (516) 765-1823
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MARRIAGE OFFICER �_�fo a�'0�� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER I
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. 1527 R Residential X Non-Residential
Fee $ 10.00 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 AN OVERFLOW TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS
BUILDINGS, AND PROPERTY LINES. EXCAVATION INSPECTION REQUIRED.
Name Of Owner THORN, ROBERT
Mailing Address 1 335 SUNSET AVENUE
City St Zip MATTITUCK NY 11952
Property Address 1 335 SUNSET AVENUE
City St Zip MATTITUCK NY 11952
Tax Map No. section 115.00 block 3 lot 12.000
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 8/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY % y1 Town Hall, 53095 Main Road
TOWN CLERK N i P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER Wif O�I'1�� Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER OlAge '1►a,J Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER 6
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED: August 14, 1996
Transmitted herewith is a copy of application No. 1593 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic Cesspool for Robert Thorn
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 following recommendation:
APPROVE -
DISAPPROVE -
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
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OFFICCOF THE TOWN CLERK ,,,,,, ,,,,"
Town of Southold ,593
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Judith T. Terry, Town Clerk %e Gy Application No.
Town Hall, 53095 Main Road Construction
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P. O. Box 1179
Southold, New York 11971 • Alteration
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Telephone $10.00 - Residential �-
(516) 765-1801l l;, ' $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 $
DATE O bf
APPLICANT NAME:
APPLICANT ADDRESS: /fi' 4-176 972.-- _
---
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERA ION:
OWNER OF PROPERTY: / �
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section //5-- Block 3 Lot I
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
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Signature of App ant
RECEIVED BY: p�
Town CI k's Office
DATE: (�/��
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