HomeMy WebLinkAboutSimon, Howard ELIZABETH A.NEVILLE �, 4r Gy� Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
REGISTRAR OF VITAL STATISTICS i Southold,New York 11971
MARRIAGE OFFICER `� , ``�,11� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ' fi;�ljig $',i• 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. 3192 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : LORRAINE SIMON
Address 1: 27 STACEY LANE
City St Zip MADISON CT 06443
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR ONE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-03-0122
Name Of Owner SIMON, HOWARD & LORRAINE
Mailing Address 1 27 STACEY LANE
City St Zip MADISON CT 6443
Property Address 1 3290 ALVAH'S LANE
City St Zip CUTCHOGUE NY 11935
-ax Map No. section 102.00 block 4 lot 6.002
Cross Street ROUTE 25
Building Permit Number Cross Reference:
Issue Date: 9/01/04 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
r �O��gUFFOl,t40 ` 5 )52---
ELIZABETH A.NEVILLE _fd‘
Town Hall, 53095 Main Road
TOWN CLERK ; y Z ; P.O.Box 1179
IAA i Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 1c4/6 $
MARRIAGE OFFICER `. �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER � �1 * �a�,��� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER 1 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
_
J 8 2004
TO: Southold Tpwn Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: June 8, 2004
Transmitted herewith is a copy of application No. 3333 for a Cesspool/Septic Tank Construction
Permit submitted by:
Lorraine Simon
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: ji�4-'�"+,�� ..40 .�`�►y
I �
Ardiclibadlher
Signature
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Dated
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ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
It TOWN CLERK ► P.O.Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ".°O4,,_ I Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER - a��lTelephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER = '� * ,„.0. southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 ✓ or Non-Residential @$25 Application No. 33 3
Permit No.
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Applicant Name iNL S I At o A)
Applicant Mailing Address ca.7 STA- 61
OGyct3
Septic Tank ✓or Cesspool
Brief Description of Proposed Construction or Alteration S,r &.
Location of Proposed Construction/Alteration:
Owner of Property: ,LO fl( c+- 0 kJ
Owner Mailing Address: A 6 , ' '
I
Owner Property Address: Nskb A L 14 ` S ,— --
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Name and phone number of contact person
Tax Map No: Section /0 .2 Block (. Lot G. 2
Cross Street -r—
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WI HEALTH D PARTMENT APPROVAL
Co 6 8/0
Signature of Applicant Da e
Received by:
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N/F CLIFFORD AND REGAN BATUELLO
1855 ALVAH'S LANE
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CUTCHOGUE, N.Y.
1000-102-04-6.1
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