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SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3410 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1: P 0 BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
-REPLACING OLD TYPE CESSPOOL WITH NEW TYPE
-MAINTAIN ALL REQUIRED SETBACKS FROM ADJACENT WELLS, BUILDINGS,
PROPERTY LINES, AND WATERBODIES
Name Of Owner EVELYN ROSHUSSON
Mailing Address 1 94 FAIRMOUNT STREET
City St Zip VALLEY STREAM NY 0000
Property Address 1 355 RILEY AVE
City St Zip MATTITUCK NY 11952
Tax Map No. section 143.00 block 4 lot 19.000
Cross Street BAY AVE
Building Permit Number Cross Reference:
Issue Date: 2/23/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE 0 O . Town Hall, 53095 Main Road
TOWN CLERK 4 4 , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
va y� Southold, New York 11971
MARRIAGE OFFICER •� . � Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �l�`, ,M �o� Telephone (631) 765-1800
FREEDOM-OF INFORMATION-OFFICER OUN 1,a ���a southoldtown.northfork.net
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FEB 6 OFFICE OF THE TOWN CLERK
-- TOWN OF SOUTHOLD
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TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3563 for a Cesspool/Septic Tank Construction or
Alteration Permit submitted by:
Peconic Cesspool
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: • -
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Aide moor.
Signature
,2/9 7/40 6
Dated
73 itA4011 4';
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am s7#WM 3WM CLERK4.1\11-11,04,4:4„,
nuzaa1 �:ivi ,TOWN CUKK Application N o3� �ACC��J
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TA,BOX 1179 '� Construction 1.../
$otttHatD,NEW YORK 11971
' Alteration
$10.00 Residential 4.
Telephone '`� . .a�� 'r' ---— -
(63t) 765-1800 '
' '; �� 1.1r,.00 Non-Residential
TOWN OF SOUTIIOI I.)
SOUTHOLD WASTEWATER DISPOSAI. DIS I RIC I
APPLICATION
for
CONSTRUCTION or ALI ERA I I(U1 Pi RMI
SEPTIC TANK or CESSPOOI.
Permit • :Al AO
Fee 'SfQ.CDO
DA I i CAA /p �
APPLICANT NAME: PECoN1C CESSPOOL
APPLICANT ADDRESS: P. 0. BOX 972
MATTITUCK, NEW YORK 11952
SEP. .IC CESSPOOL ✓'"
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
;,. • I
CTL N4 MAP: Must be attached hereto before permit may lie issued.
LOf' T1N RF PROPOSED CONSTRUCTION OR ALTERATION:
Tp,w0tER, OF PROPERTY: ,1
OWNER MAILING ADDRESS: /3
OWNER PROPERTY AODRESg. • �_p���
TELEPHONE NUMBER OF CONTACT PERSON : G 5 f r a 4' G Sg
,Ox MAP NO. : Section / I/3 Block 1/ Lot / f
commis-STREET
. BUILDING PERMIT NUMBER CROSS REFER ICI :
Siy1 nature of A Ilcant
RECEIVED BY:' ON,
own Terk s Office _ _..
DATE i0,n
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