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ELIZABETH A.NEVILLE ��� '`�y> l01 Town Hall,53095 Main Road
TOWN CLERK alli P.O. Box 1179
�„� Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS G �
MARRIAGE OFFICER '% — Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER � -(4- u �A ••� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER OVI1rV 1�, •11� 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. 3365 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1: P. 0. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
-REPLACE OLD CESSPOOL WITH NEW TYPE
-MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS, BUILDINGS, PROPERTY
LINES, AND WATER BODIES. EXCAVATION INSPECTION REQUIRED
Name Of Owner SCOTT RUSSELL
Mailing Address 1 P. O. BOX 547
City St Zip CUTCHOGUE NY 11935
Property Address 1 515 OAK STREET
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 136.00 block 29 lot 1.000
Cross Street HARBOR LANE
Building Permit Number Cross Reference:
Issue Date: 9/28/05 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE e 1, \ Town Hall, 53095 Main Road
TOWN CLERK 4g ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS i4c. Southold, New York 11971
MARRIAGE OFFICER � �Q 1�, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �lv ��� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER .v CQU ,� ���� southoldtown.northfork.net
2 2 2005 OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
L.
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: September 20, 2005
Transmitted herewith is a copy of application No. 3511 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Scott Russell
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 location 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.
7/7447 i.‘t
Signature
2-2 Adios”
Dated
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P.O.BOX 1179
SOUI110LD,NSW YORK 11911
u. (1u Residential
Telephone : . ��(
'�►�O"��
(631) 765-1800 ' 1 1 .1111 lion Residential
TOWN OF SOU Hit)! I)
SOUTHOLD WASTEWATER 01`;I'trSAI DIS IU11I
APPLICAT It./14
for
CONSTRUCT ION or ALI t:I:A I 'MI PI MI I
SEPTIC TANK or Ct:SSI'1111I.
Permit No. 991_07)
Fee .$
DA I 1: 6./01..
APPLICANT NAME: PECONI C: CESSPOOL
APPLICANT ADDRESS: P. 0. BOX 972
MATT NEW YORK 11152
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit way he issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALi'l RATION:
, OWNER OF PROPERTY : 5 O //1 RU594-1/
OWNER MAILING ADDRESS: Rd /' C S7
CU�� � fl✓ �-' // g35-
OWNER PROPERTY ADDRESS: 'S� O,qA .S '
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TELEPHONE NUMBER OF CONTACT PERSON "3/
;TAY MAP NO. : Section /3 Cr block c q 1 o
CROSS STREET: ,C.�j,A__17 ylu
BUILDING PERMIT NUMBER CROSS REFER ICI :
iecoer_4�� \
Siyl a;it.o e of Al )ficarlt
RECEIVED BY: .451/617)
Town cler is_0 ice - -
DATE:
-DATE:
Town Of Southold
• P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/20/05 Receipt#: 9005
Transaction(s): Reference Subtotal
1 1 Septic Permit-Construct- Resid. 3511 $10.00
Check#: 9005 Total Paid: $10.00
Name: Peconic, Cesspool
P 0 Box 972
Mattituck, NY 11952
Clerk ID: LINDAC Internal ID:3511
SCOTT RUSSELL
515 OAK STREET
CUTCHOGUE
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