HomeMy WebLinkAboutRoss, Pam SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3474 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : THOMAS C. SAMUELS
Address 1: 25235 MAIN ROAD
City St Zip CUTCHOGUE NY 11935
Descripton of Proposed Construction or Alteration
-ABANDONMENT OF EXISTING SYSTEM, CONSTRUCTION OF A NEW SANITARY SYSTEM
-FINAL APPROVAL REQUIRED FROM THE SUFFOLK COUNTY HEALTH DEPARTMENT
Name Of Owner PAM & NANCY ROSS
Mailing Address 1 3250 PARK AVE.
City St Zip MATTITUCK NY 11952
Property Address 1 SAME AS ABOVE
City St Zip 0000
Tax Map No. section 123.00 block 8 lot 2.220
Cross Street PARK AVE.
Building Permit Number Cross Reference:
Issue Date: 10/27/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
00 SOF S0045,
-
ELIZABETH A. NEVILLE * ,`O l0 Town Hall, 53095 Main Road
TOWN CLERK411
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS % c/a Southold, New York 11971
MARRIAGE OFFICER O. 1,� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER % O ,�a �1� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER `I'COU ,' is. southoldtown.northfork.net
OFFICE OF THE TOWN CLERK PP,
TOWN OF SOUTHOLD
c. D 15 S
TO: Southold Town Building Department
FROM: Michelle L. Martocchia, Southold Town Clerk's Office
DATED: September 14, 2006
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 3628 for a Cesspool/Septic Tank
Construction/Alteration Permit submitted by:
Thomas C. Samuels
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: -
11/
J
Signature /1"..e
4/0/4
Dated
OFFICE OFTHE TOWN CLEitIC eeree�e"'••�.,��I
TOWN OF SOUTHOLD : C��" 0��1
FII7ABETHA.NBVILLE,TOWN CLERK /4"
� Ol/y�: Application No (02-g
Construction
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 a
fn. Alteration
Telephone 4. ��/ $10.00 - Residential X
(631:) 765-1800 �l �eee'' $25.00 -Non-Residential
„„ore
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.”9c4 �
y
Fee .$
DATE 91//4767
APPLICANT NAME: Thow4 j` 0, Eamust
APPLICANT ADDRESS: &50235 I oars(
t t(44-(14,=-6�
SEPTIC / CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
Alet. or
o f tp ctcr d L4
(e-141,
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONS RUCTION OR ALTERATION:
•
• OWNER OF PROPERTY: ram/ 1I(944 '
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: d250 Paik �CLe
filati Jude, I.y.
TELEPHONE NUMBER OF CONTACT PERSON: 73L/ - *05'
TAX MAP NO. : Section 03 Block 03 Lot oWr 2
CROSS STREET: &-k ki u e
BUILDING PERMIT NUMBER CROSS REFERENCE:
eX7 •
•
Signature of Applicant
RECEIVED BYTYp9
ow lerk's Office
DATE: 9. I
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