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JUDITH T. TERRY , •� iC Town Hall, 53095 Main Road
TOWN CLERK ` =G T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �l� • Southold, New York 11971
Fax 3
MARRIAGE OFFICER 1":10,& ����" � Telephone(516)
el phonel(516)5765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 668 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : INLAND HOMES, INC.
Address 1 : 315 WESTPHALIA ROAD
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 11/14/90.
Name Of Owner BALLOT, PAUL
Mailing Address 1 30 SUYDAM DRIVE
City St Zip MELVILLE NY 11747
Property Address 1 HALLOCK LANE
City St Zip LAUREL NY 11948
Tax Map No. section 112.00 block 1 lot 2.000
Cross Street SOUND AVENUE
Building Permit Number Cross Reference:
Issue Date: 12/06/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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7611,7; DEBT. " __ .• Town Hall, 53095 Main Road
TOWN OF SOUTHOLD._-�. .�.....�,,,.....,.._ ' �p'� ' NN' :�
'� • P.O. Box 1179
*(�/. � 0 Southold New York 11971
JUDITH T.TERRY
1.. TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Code Enforcement Officer Li ff'
From: Linda Cooper, Southold Town Clerk's Office (1),0111) V
Dated: November 27, 19907(
Transmitted herewith is a copy of application No. 682 for a Cesspool/
Septic Tank Construction Permit submitted by:
Inland Homes Inc for Paul Ballot .
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE __X
DISAPPROVE
Comments: p„ An.% c a.Le a., cry, cat a C .. .0
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Signature
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Dated
QFFICE OF,THE .TOWN CLERK
Town of Southold Application No.AW4(Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Construction _
P. 0. Box 1179 Alteration M w
Southold, New York 11971
Telephone • Residential
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTIIOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $10.00
DATEENovember 2l, 1990
APPLICANT NAME: Inland Homes,_Inc.
APPLICANT ADDRESS: 315 Westphalia $d:____
Mattituck , N. 1,13.3.52 _. _---
SEPTIC CESSPOOL X
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
1 family dwelling
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY. Paul Ballot
OWNER MAILING ADDRESS: 30 Suydam Drive
Melville, N. T. . 11741
OWNER PROPERTY ADDRESS: Hallock Lane
Laurel; N. I.
TELEPHONE NUMBER OF CONTACT PERSON: 298-9696
TAX MAP NO. : Section 112 Block 1 Lot 2
•
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
1
tk
Signature
o`" Apr' nt
Robert E. Hiltz, Ir.
RECEIVED BY: y
RECEIVEDWn Clerk's Office
DATE:
loom Clerk Sout teld
.....,.......,..................m.
SUFF'LK CO. HEALTH DEPT. APPROVAL
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U12BAN1F....L.1..0 & DELEEUW H. S. NO..
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SCALE- 50.1 . ..
......." . ............... .4. • ft.
AREA t 52„.500 a E .1.. (31;,000.rop W. ± io )\I - 14 199° ... STATEMENT OF INTENT
-.....
--..,..., Q. MONUMENT
... ,..:,k THE WgER SUPPLY AND SEWAGE DISPOSAL
•
- -. I ',2 '' Of SYSTEWS FOR THIS RESIDENCE WILL
, \ i : SkOilitia-kONFOFM TO •THE STANDAR' OF THE
SUFFOLK CO. Ir. Irt•-i-A, - ICES.
APPLICANT
CES5 POOL ,
"N 1 1 SUFFOLK COUNTY DEPT. OF HEALTH
I i . i 1.,„.-1 SERVICES - FOR APPROVAL FOR
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\ 111 CONSTRUCTION ONLY
/ I I DATE:
WELL H. S. REF. NO -
APPROVENeo
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APPROVED:
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. / L___J W SUFFOLK CO. TAX MAP DESIGNATION:
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1 1 DIST. E ' . BLOCK PCL.
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700 — OWNERS ADD- 5:
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