HomeMy WebLinkAboutKellner, Steven c
SCUTHCLD WSTEVIATER DI SPCGAL PERM T
CCNSTRI CTI CN CR ALTERATI CN PERM T
SEPTI C TANG or CESSPCCL
Perm t Nb. 4178 R Flesi dent i al X Nbn-Ibsi dent i al
Fee $ 10. 00 Septic X Cesspool
PERM T I SStED TO
Narre : PECCN C CESSPCCL
Addr ess 1: P O BCts( 487
City St Zip LAUREL NY 11948
Cescr i pt on of Proposed Const r uct i on or Al t er at i on
AW TI CN TO EXI STI N3 SYSTEM
APPRCWED AS SLEM i i W. MSI NTAI N RECD FED SETBACKS FROM ADJACENT
WELLS, BU LD NGS, PROPERTY LI NES AN) MATER BCDI ES.
Nam a Owner STEVEN KELLNER
Mai I i ng Addr ess 1 5535 V'ESTPHALI A ROAD
a t y St Zi p NATTI TUCK NY 11948
Property Addr ess 1 5535 V'ESTPHLLI A ROAD
City St Zip MUTI TUCK NY 11948
Tax Map Nb. section 113. 00 bl ock 12 I of 5. 000
Cr oss St r eet I LLI NCI S AVENLE
Bui I di ng Per m t Nunber Cr oss Fef er ence:
Issue Dat e: 12/27/ 13 Elizabeth A Nevi I I e
Sout hold Town a er k
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��of'•OFF0I4-
ELIZABETH A. NEVILLE,MMC '���yO �l/y Town Hall,53095 Main Road
TOWN CLERKP.O. Box 1179
H 2 $ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS *. 0 Fax(631)765-6145
MARRIAGE OFFICER `‘ '*4, ��'��� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER 6.( iii •a i'
FREEDOM OF INFORMATION OFFICER --'- ....,,•0‘i
��� www.southoldtownny.gov
OFFICE OF THE TOWN CLERK I i FIs) 17:517
TOWN OF SOUTHOLD ��, — '�� i
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t� L` DEC -2 2013 f; I�
\TO: Southold Town Building Department
{
FROM: Carol Hydell, Southold Town Clerk's Office T� c �„ ) 'jrmn
DATED: December 2, 2013
Transmitted herewith is a copy of application No. 4178 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Steven Kellner
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. .
Signature
-.4(4.1 --
/47--%3
41/47-- /3
Dated
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ELIZABETH A.NEVILLE i Town Hall, 53095 Main Road
TOWN CLERK h Z $ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ‘O /�� Southold, New York 11971
MARRIAGE OFFICER '41 0.ri Fax(631) 765-6145 „
RECORDS MANAGEMENT OFFICER -___O 4 -►a••i$ Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ..,,,..�'" southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
cerAPPLION t ,Q
j,j,,,..-A___
CESSPOOL or SEPTIC TANK
Residential $10 �or Non-Residential $25 Application No. 4 f
@ @ pp
Permit No.
Owner Name ��tiU��% /�
Owner Mailing Address 5--3 3 ) c% 1` / Le l
Na,( 71-(4
Owner Property Address t. 5-3 5____
riA,a,, ,,L ,,,(
,,,,
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Owner Telephone No. oC 9if---F3 7 7
Tax Map No: Sect' � n t LS Block , , Lot 5
Cross Street j6/1a.
/J £% "c-
Please check each that applies: New Construction
Alteration to Exist' g System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction ma submit copy • survey with SCHD ap•royal.)
/ •
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' Si
gnature
,o of Applicant
Received by: ( e f c/02- ` Mo2
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* * * RECEIPT * * *
Date: 12/02/13 Receipt#: 159799
Quantity Transactions Reference Subtotal
1 Septic Permit-Construct- Resid. 4178 $10.00
Total Paid: $10.00
Notes:
Payment Type Amount Paid By
CASH $10.00 Peconic, Cesspool
Name: Peconic, Cesspool
P 0 Box 487
Laurel, NY 11948
Clerk ID: LYNDAR Internal ID:4178