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JUDITH T. TERRY ��
.G Town Hall, 53095 Main Road
TOWN CLERK : Z t P.O. Box 1 179
C Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER V/ •koO
.�� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 733 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
REPLACE OLD CESSPOOL WITH NEW TYPE.
APPROVED AS SUBMITTTED. OLD CESSPOOL MUST BE REMOVED AND DISPOSED OF
PROPERLY. DO NOT BURY.
Name Of Owner CZECH, THERESA
Mailing Address 1 4 GOLDEN LANE
City St Zip SOUTHOLD NY 11971
Property Address 1 4 GOLDEN LANE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 135.00 block 2 lot 19.000
Cross Street NORTH ROAD
Building Permit Number Cross Reference:
Issue Date: 7/24/91 Judith T. Terry
Southold Town Clerk
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JUDITH T. TERRY
"' " TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
June 25, 1991
To: Southold Town Code Enforcement Officer
From: Linda J. Cooper, Southold Town Clerk's Office
Transmitted herewith is a copy of application No. A751 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic Cesspool for Theresa Czech
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 this office.
Thank you.
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE - Y
DISAPPROVE -
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.E OF THE TOWN CLERK ,,,'"'," --.
Town of Southold C�VFFD��CD - Application No. i •-•
ith T. Terry, Town Clerk / G
own Hall, 53095 Main Road i° Construction
P. O. Box 1179 ` ,i, 4
Southold, New York 11971 •tJ's Alteration
Telephone Q�;�, $10.00 - Residential C�
(516) 65-1801l ��
- � '' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPT I C TANK or CESSPOOL
Permit No.
Fee $
DATE " q
APPLICANT NAME: 'G� i J�C:Z
APPLICANT ADDRESS: ":0 A-0-2- 99 2
. - - fly
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: l� 2- -e- � -
OWNER MAILING ADDRESS: If
, ‘'S-17-1L/eX-0-Zel ill
OWNER PROPERTY ADDRESS:
TELEPHONE
DDRESS:TELEPHONE NUMBER OF CONTACT PERSON: D-7d -5 6, 5e
TAX MAP NO. : Section I S Block eq- Lot
CROSS STREET: 1' �-- /✓t
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applica
RE. EP/EO BY:
own Clerk's Office
DATE: p `2- /`7T'
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