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HomeMy WebLinkAboutKrom, Ann o�OS�FFO�,�cOG ELIZABETH A. NEVILLE �� y� Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS �y • �� Southold, New York 11971 MARRIAGE OFFICER Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER ��,� .��� Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT CONSTRUCTION OR ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. 3129 R Residential x Non-Residential Fee $ 10.00 Septic x Cesspool PERMIT ISSUED TO: Name : PECONIC CESSPOOL Address 1: PO BOX 972 City St zip MATTITUCK NY 11952 Descripton of Proposed Construction or Alteration ADDITION TO EXISTING SYSTEM. APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION INSPECTINO REQUIRED. Name Of Owner KROM, ANN ------------------------------ Mailing Address 1 PO Box 545 ------------------------------ ------------------------------ City St zip LAUREL NY 11948 -------------------- -- ---------- Property Address 1 1280 PECONIC BAY BLVD ------------------------------ ------------------------------ City St zip LAUREL NY 11948 -------------------- -- ---------- Tax Map No. section 145.00 block 2 lot 12.000 ------ --- ------ Cross Street LAUREL LANE ------------------------------ nilding Permit Number Cross Reference: ---------------------------------- Issue Date: 1/29/04 Elizabeth A. Neville -------- Southold Town Clerk (TOWN SEAL) t t R JR o�os�FFo��coG � 1 z� ELIZABETH A.NEVILLE �� y� Town Hall, 53095 Main Road TOWN CLERK C = P.O. Box 1179 REGISTRAR.OF VITAL STATISTICSSouthold, New York 11971 MARRIAGE OFFICER y O!� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ��,� .�`a Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TO: Southold Town Building Department DEC I I M FROM: Linda J. Cooper, Southold Town Clerk's Office DATED: December 11, 2003 Transmitted herewith is a copy of application No. 3264 for a Cesspool/Septic Tank ALTERATION Permit submitted by: Peconic Cesspool for Ann Krom 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. * * * * * * * * * * * * I have reviewed the application and locati map of the project cited above and make the following recommendations: APPROVE DISAPPROVE Comments: Maintain required setbacks from adjacent wells, buildings,property lines and water Bodies. EXCAVATION INSPECTION REQUIRED. Signature /,)- i 7 /,4035 Dated ar R 1 OFFlCR OF THE TOWN CUMK �FFDLk Application A .�� ` TOWN OF®OVrHOLD � p p No- BLIZABETB A.NEVW.B,TOWN CLERK �'�► P.O.BOX 1179 soVrHoLD,NEW YORK 11971 A l to ra t i o n Telephone 0 �Q� $10.00 - Residential (631) 765-1800 �l° $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 APPLICANT NAME: PECONIC CESSPOOL APPLICANT ADDRESS: P. 0. Box 972 MATTITUCK, NEW YORK 11952' SEPTIC CESSPOOL DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION r LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: rI OWNER OF PROPERTY: 41/I1 /�R © /" OWNER MAILING ADDRESS: lQ6joe ,51 L.. //, 4' / g 9,9 OWNER PROPERTY ADDRESS: /9�?_8O /O��N��- �g TELEPHONE NUMBER OF CONTACT PERSON: TAX MAP NO. : Section 1 '�� –Block—49-., 0 Lot oz�0 CROSS STREET: �C BUILDING PERMIT NUMBER CROSS REFERENCE: Signature ofuApplicant RECEIVED BY: Town ffice DATE: l (l D k 186 Ann Krom 1280 Feconic Bay Boulevard L8ui�1