HomeMy WebLinkAboutKempner, Ann SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3469 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : ANN T. KEMPNER
Address 1: P.O. BOX 1718
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
-REPLACING EXISTING SYSTEM
-MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS, PROPERTY LINES,
BUIDLINGS, AND WATER BODIES.
Name Of Owner ANN T. KEMPNER
Mailing Address 1 P.O. BOX 1718
City St Zip SOUTHOLD NY 11971
Property Address 1 270 GOLDEN LANE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 135.00 block 2 lot 21.000
Cross Street
Building Permit Number Cross Reference:
Issue Date: 9/18/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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• 1 • AN%OFSO�lgol -
ELIZABETH A. NEVa ILLE '`
� ‘ Town Hall,53095 Main Road
TOWN CLERK i 4I 4 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS G Q ,�
Southold, New York 11971
MARRIAGE OFFICER 1 3 �O r Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER l �1 Telephone (631) 765-1800
FREEDOM OF INFORMATION-OFFICER
'yCOU '��,; ', southoldtown.northfork.net
(6 northfork.net
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2006OFFICE OF THE TOWN CLERK
SEP - 5TOWN OF SOUTHOLD
4. ~Sout iold Town Building Department 3c i—,�
FROM: Michelle L. Martocchia, Southold Town Clerk's Office '�'j
DATED: September 1, 2006
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 3624 for a Cesspool/Septic Tank
Construction/Alteration Permit submitted by:
Ann T. Kempner .
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 me. Thank you.
* * * * * * * * * * * *
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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Signature
05/6. d6,
Dated
,,i/iii,��
ELIZABETH A.NEVILLE lei00 et, Town Hall, 53095 Main Road
*
TOWN CLERK 1 • P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ! �yy M $ Southold, New York 11971
MARRIAGE OFFICER Fax 44.�0 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =4;# a0�,�iI Telephone (631)765-1800
FREEDOM OF INFORMATION OFFICER = '� * i�. 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 I. . a,y
Permit No
it,
Applicant Name /9/ik/ l /Kit-n41/6-/C
Applicant Mailing Address /g /J 1 V /7/k
Septic Tank or Cesspool
Brief Descriptio. of Proposed Construction or Alteration /i./ ,e4,t, /A
Location of Prop!ed Construction/Alteration:
Owner of Property: ni7l//1/ 7 /(/,f/C
Owner Mailing Address: /6 Q • )07/ r
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Owner Property Address: d7d p4 f/- X/197r71-
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Name and phone number of contact person 1 low -,3(_i
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Tax Map No: Section '35 Block cQ Lot c2 I
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WIT ALTD PARTMENT APPROVAL
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Signature of Applicant / Date
Received by
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