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SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 4053 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1: P 0 BOX 487
City St Zip LAUREL NY 11948
Descripton of Proposed Construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WET,T4, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner ANN FLISS
Mailing Address 1 715 BRAY AVENUE
City St Zip LAUREL NY 11948
Property Address 1 715 BRAY AVENUE
City St Zip LAUREL NY 11948
Tax Map No. section 126.00 block 2 lot 6.000
Cross Street ALBO DRIVE
Building Permit Number Cross Reference:
Issue Date: 1/31/12 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
1,11111• 111117'
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ELIZABETH A.NEVILLE,MMC ��„� 4 Town Hall,53095 Main Road
TOWN CLERK ? P.O.Box 1179
2 Southold,New York 11971
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REGISTRAR OF VITAL STATISTICS
O � Fax(631)765-6145
MARRIAGE OFFICER ` 'y 0�'/ Telephone(631)765-1800
RECORDS OF
FREEDOM OF IMN AGEMENT OFFICER RMATION OFFICER cf.( ,�a��', southoldtown.northfork.net
NFOFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: October 20, 2011
Transmitted herewith is a copy of application No. 4053 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Ann Hiss
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.
ignature
//
Dated
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F;, AR�l A. i�. ` Town Hall,53095 Main Road
TOWN CLERK ,.f ti P.O.Boa 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MABR1AGE OFFICER • • Fax Pax(631)765-6145
RECORDS MANAGEMENT OFFICER �; ,s' Telephone(631)765-1800
FREEDOM OF fl ORMATION OFFICER = * southoldtown.northforknet
OFFICE OF'TOWN CLERIt
• TOWN OF SOUTHOLD
SO UTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
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Residential $10or Non-Residential @$ZSApplicaton No. &4 C 53
Permit No.
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Applicant Name PECONIC CESSPOOL
Applicant Mailing Address P. o. BOX .487
LAUREL, NEW YORK 11948
Septic Tart or Cesspool ;
Brief Desc: hon of• •�'•sed fiction or Alteration nvt �`'
✓ Wi cess t roe (res-5/10—dot--
Location of Proposed Constmo ionIAlte tion.- / r
Owner of Property: 7 11 f t Lc S S
Owner'Mailing Address:
Owner Property Address: 7/5- ave-
- La-/Are / N f f 9
Name and phone number of contact person / %77l''l/ 57 0-"?
Tax Map No: Section, P CI,• Block Lot C,
Cross Street fI)- `Q..
NOTE: LOCATION MAP MUST BE SUMMED APP CATION. NEW
CONSTRUCTION REQUIRES SURVEY ' : :r - ' :+DEPAR Vi .. '"ROYAL
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Signature o ; t ,.t Date
Received by: - • _ .
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