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JUDITH T.TERRY �I ?1`% Town Hall, 53095 Main Road
TOWN CLERK ; y 1 P.O. Box 1179
v►% "i t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ��'�,� Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER - O•j *a0',� Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,•as
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1655 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 CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS
BUILDINGS, PROPERTY LINES, AND WATER BODIES. EXCAVATION INSPECTION
REQUIRED.
Name Of Owner TESE-MILNER, ANGELA G.
Mailing Address 1 ONE MINETTA LANE
City St Zip NEW YORK NY 10012
Property Address 1 500 BROADWATERS ROAD
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 104.00 block 10 lot 5.000
Cross Street VANSTON ROAD
Building Permit Number Cross Reference:
Issue Date: 5/12/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
rt" Town Hall, 53095 Main Road
C77d 1L 5/02 4 P.O. Box 1 179
I11 , lf►O IN, Southold, New York 11971
JUDITH T.TERRY •�1 Pik TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR 01.VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
f)ATEI): April 21 , 1997
Transmitted herewith is a copy of application No. 1721 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic Cesspool for Angela G. Tese-Milner
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 followin recommendation:
APPROVE -
DISAPPROVE -
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
RECEIVED
Signatu'e
MAY 8 1997 5
77 Da e
Southold Town Clerk
OFFICE OF THE TOWN CLERK ,,,,,,,,,,, , -
Town of Southold '• �FFDtk� 4 Application N/ —. /
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road `Q = Construction
P. O. Box 1179 1 ; Alteration
Southold, New York 11971 crs
,
Telephone \y�,j' lir . $10.00 - Residential
P �'
(516) 765-1801
' * ' $25.00 -Non-Residential
•TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ DATEW>41
7 —_
APPLICANT NAME: - - --- —
APPLICANT ADDRESS:__ 74-7/y 7-2--
‘101 _
SEPTIC CESSPOOL_
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALT RATION:
OWNER OF PROPERTY :
OWNER MAILING ADDRESS:
_ - `J` /4.1./t, 0 10° /`"--
OWNER PROPERTY ADDRESS: S 40
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section /4 Block !O Lot
CROSS STREET : t/
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED Signatur of Applicant
RECEIVED BY : c2 1 1997
Town erk's Office
DATE:
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