HomeMy WebLinkAboutKrstulovic, Stephanie I
SCUTHCLD V111STBAATER q SP06AL PERM T
CONST UCTI CN CR ALTERATI CN PERM T
SEPTI C TANK or CESSPOOL
Per m t Nb. 4172 R Resi dent i al X Nbn-Fbsi dent i al
Fee $ 10. 00 Septic X Cesspool
PERM T I SSIED TQ
Narre : 00%9111W CESSPOOL & DRAI N
Address 1: 4225 BR DCE LANE
CI t y St Zip curcHccIE NY 11935
Descr i pt on of Pr oposed Const r uct i on or Al t er at i on
ADDI TI CN TO EXI STI NG SYSTBUI
APPRCXED AS SU3M TTEQ MSI NTAJ N REOU FED SETBACKS FROM ADJACENT
YELLS, BU LDI NGS, PITY LI NES AND MATER BCD ES.
EXCAVATI CN I NI,SPECTI CN RECD RED
Nana Cf Owner STEPHAN E KRSTLLOA C
Ii Ii ng Address 1 609 VEST 114TH ST 62
CI t y St zi p NEVVYCRK W 10025
Pr oper t y Addr ess 1 335 SOUTH ER VE
Q t y St Zi p NATTI TUG( NY 11952
Tax I,bp Nb. section 106. 00 bl ock 11 I of 19. 000
Cr oss Street BAY MERE
Bui I di ng Per rri t NUnber Q'oss Ref er ence:
Issue Date: 1/02/ 14 Elizabeth A LevilIe
Sout hold Town Q er k
,/ ,o\,gUFFO[,r�o
ELIZABETH A. NEVILLE,MMC 1/4y► l/,j,\ Town Hall, 53095 Main Road
TOWN CLERK o A 1 P.O. Box 1179
H 2 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS p Fax Fax(631)765-6145
MARRIAGE OFFICER `�y ���� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER -791 -0„ www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER �'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
OCT 2 5 2013
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: October 24, 2013
Transmitted herewith is a copy of application No. 4172 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
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
/6'4-0
Dated
1', $vrll 0 - _
ELIZABETH A.NEVILLE ;, * \ Town Hall, 53096 Main Road
TOWN CLERK A ` P.O.Box 1179
'` Z ` Southold New York 11971
REGISTRAR OF VITAL STATISTICS t '
MARRIAGE OFFICER '�10 Fax (631) 765-6145
RECORDS MANAGEMENT OFFICERa0�e'' Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER = '� *''�'+.'0 eoutholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT •
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 V'or Non-Residential @ $25 Application No. of 1'1
Permit No.
Applicant Name CQ \\nQ `1n��� C 7\ c' am \n .S'x -e__�� (?. Y `C°
Applicant Mailing Address kcie-At. L) .
•
e svc-tr,ce A- \ \\ \
Septic Tank ✓or Cesspool , -
Brief Description of Proposedonstruction or Alteration_' \\ C 1> \(-)._-iTh c 11
Se &c° 's-r�.�\< C 1� 6X 1, - \ecic \ c—^h\
Location of Proposed Construction/Alteration:
Owner of Property: . Y\C3c(1\� 1 \C-SA-0\CA) \C
Owner Mailing Address: -Q CR W05--\-• \\ SSA , L4 a
v. c . i.._ ____\ \c-i--) ,5
Owner Property Address: 3.-. --, St`x) r\Th Of: \Vt?
Name and phone number of contact person L \\ Ch Y K - '--)1U - ,. —+
Tax Map No: \O00Section \C ko Block I ` Lot (a
Cross Street u \ \ (1 X
NOTE: LOCATION MAP MUS BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRE URVEY HEALTH DEPARTMENT APPROVAL
f
( .--4-'1005‘.) G. , - VD-22-- 13
\ litre of Applicant • Date •
Received by: `'
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