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JUDITH T. TERRY 'L Town Hall, 53095 Main Road
TOWN CLERK p rZ P.O. Box 1179
cls �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = VO �. ��� Fax (516) 765-1823
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MARRIAGE OFFICER = ' �.O .' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 1 4 .�
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FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1275 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
ADDITION OF AN OVERFLOW CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION
INSPECTION REQUIRED.
Name Of Owner BLESCH, EDWIN
Mailing Address 1 BOX 330
City St Zip ORIENT NY 11957
Property Address 1 MAIN ROAD
City St Zip ORIENT NY 11957
Tax Map No. section 18.00 block 1 lot 14.000
Cross Street YOUNDS AVENUE
Building Permit Number Cross Reference:
Issue Date: 1/19/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY '1 = yet % Town Hall,53095 Main Road
TOWN CLERK , y x % P.O.Box 1179
��1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ' G Fax(516)765-1823
MARRIAGE OFFICER y/fJ O' /
RECORDS MANAGEMENT OFFICER c �.( * 4) .. Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER �. ,,so'
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OFFICE OF THE TOWN CLERK `:u jAii 9pag5 L
TOWN OF SOUTHOLD t
TO: Southold Town Building Department
BLDG.DEPT.
FROM: Linda Cooper, Southold Town Clerk's Office TOWNOFSOUTHOLD
DATED: January 6, 1995
Transmitted herewith is a copy of application No. A1322 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic Cesspool for Edwin Belsch .
Please review the application and location map and advise if this office may
issue the permit.
Please complete the form below and return it to this office.
Thank you. , ^
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE EXCAVATION INSPECTION
DISAPPROVE - REQUIRED
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
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Signatu
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Date
OFFICE OF ,THE TOWN CLERK ""
'own of Southold �' •��FF�tKt+`
Judith T. Terry, Town Clerk ;'#% l/ Application No. /4 Lt._Town Hall, 53095 Main Road Construction C�
P. 0. Box 1179 � .
Southold, New York 11971 :Vs yc ; Alteration
Telephone G4, ��� .�•• $10.00 - Residential
(516) 765-1801 1jrit
���,,� '• $25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE 0J /e17/95
APPLICANT NAME: AgrA11517,
APPLICANT ADDRESS: "QL7 9 z
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTE . ION
(54
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERAT ON•
OWNER OF PROPERTY: �%
OWNER MAILING ADIA0330 ,--
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OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: Off— �� cr
TAX Mr' P NO. : Section f i Block / Lot /-A
C cc STREET:
BUILDING PERMIT NUMBER CR SS REFERENCE:
Signature of Ap. cant
RECEIVED BY:
Town Clerk's Office
DATE:
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