HomeMy WebLinkAboutBertsch, William SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 4130 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : WILLIAM BERTSCH
Address 1: 60 SCHUTTER LANE
City St Zip OYSTER BAY NY 11771
Descripton of Proposed Construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner WILLIAM BERTSCH
Mailing Address 1 60 SCHUTTER LANE
City St Zip OYSTER BAY NY 11771
Property Address 1 2395 VILLAGE LANE
City St Zip ORIENT NY 11957
Tax Map No. section 6.00 block 5 lot 2.000
Cross Street NAVY STREET
Building Permit Number Cross Reference:
Issue Date: 12/27/12 Elizabeth A. Neville
Southold Town Clerk
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ELIZABETH A.NEVILLE,MMC 04 0 l/.f,; Town Hall,53095 Main Road
TOWN CLERK p P.O. Box 1179
H 2 t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS p 47$ Fax(631)765-6145
MARRIAGE OFFICER 416 0. ,•0 Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER _701 � �'• "�� D ��� ���
FREEDOM OF INFORMATION OFFICER ,�,,,,.•' _ /]
OFFICE OF THE TOWN CLERK DEC 2 1 2012
TOWN OF SOUTHOLD
E3l[G DEPT.
TO: Southold Town Building Department rev:, car`3IHHHO[D
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: December 21, 2012
Transmitted herewith is a copy of application No. 4130 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
William Bertsch
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. Thank you
* * * * * * * * * * * *
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.
714-1'..-'-"(77/1"3 )4WA,X._
Signature
Dated
off NA.
ELIZABETH A. NEVILLE ��h`t` Gy ; Town Hall, 53095 Main Road
TOWN CLERK p ; P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS ` Southold, New York 11971
MARRIAGE OFFICER L O `�� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ;_y�f O ��� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER :O' ',.• 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 Zor Non-Residential @ $25 Application No. 9/-3n
Permit No.
Applicant Name Al//Ayri
Applicant Mailing Address 6Ot�r����ic
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Septic Tank ✓or Cesspool
Brief Description of Proposed Construction or Alteration .4.4/, .2-A'otic/
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Location of Proposed Construction/Alteration:
Owner of Property: /.. "24 -4
Owner Mailing Address: 5 i—. 5
d'IEJO' B.9y //77/
Owner Property Address: c:73 75 "i.,'-'/%0:3/e--
Name
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Name and phone number of contact person �//r, �• .3/�903rS39
Tax Map No: Section dec, Block 0.5"5 Lot Q2
Cross Street ..�/e
- 04
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WIT HEALTH PARTMENT APPROVAL
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Signature of Applicant Date
Received by: (14-.(
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