HomeMy WebLinkAboutBoergesson, William �cif FOLIrceG"
JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK Z i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
040 . or Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 717 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : WILLIAM AND VALERIE BOERGESSON
Address 1 : 4860 ROCKY POINT ROAD
City St Zip EAST MARION NY 11939
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 5/13/91 .
Name Of Owner BOERGESSON, WILLIAM & VALERIE
Mailing Address 1 4860 ROCKY POINT ROAD
City St Zip EAST MARION NY 11939
Property Address 1 HARBOR LANE
City St Zip CUTCHOGUE NY 19135
Tax Map No. section 103.00 block 1 lot 20.006
Cross Street ROUTE 25
Building Permit Number Cross Reference:
Issue Date: 5/30/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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_,1 Town Hall, 53095 Main Road
\y"� ,., :''-N . , ,,,/ P.O. Box 1179
if), , ,,, Southold, New York 11971
JUDITH T.TERRY TELEPHONE
TOWN CLERK (516)765-180I
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK •
TOWN OF SOUTHOLD
To: Southold Town Code Enforcement Officer
From: Linda Cooper, Southold Town Clerk's Office
Dated: May 17, 1991
Transmitted herewith is a copy of application No. 736 for a Cesspool/
Septic Tank Construction Permit submitted by:
William and Valerie Boerqesson .
-
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 OC
DISAPPROVE
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FILE OF THE TOWN CLERK (JO,FOtkp
Town of Southold Dom,
Town Clerk Z I x-c'* Application No.73,6
Judith T. Terry, .,r
Town Hall, 53095 Main Road c 1."4. r '-
� ,. , � � � Construction (--
P.
P. O. Box 1179 aR ,:,,
Southold, New York 11971 0 Alteration
Telephone
40 * '0 Residential•
v�
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ /a
DATE S_- 16 , .11
APPLICANT NAME: & `( ,?
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APPLICANT ADDRESS: YS-6 c) be/L-7 / �C /'(1 ,
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SEPTIC t/ CESSPOOL Y
DESCRIPTION OF PROPOSED/ /
CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: V< I4'/i i' C UV r t((/am 2:9er (S' S
OWNER MAILING ADDRESS: .c.,,e c b,,,.p
OWNER PROPERTY ADDRESS: (--7G/ ‘o/ L«,e ( rc 1O7� 1
TELEPHONE NUMBER OF CONTACT PERSON: r,--() f77.-v3f'p-
TAX MAP NO. : Section ('� 5 Block ( / Lot 02 G C
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_ CROSS STREET: T, .)--C---
BUILDING
)--S�BUILDING PERMIT NUMBER CROSS REFERENCE:..
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Signature , Applicant
RECEIVED BY: el I
T wn lerk's Office
DATE: 5/Co C�
ti„ y
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JA SUFFOLK CO. HEALTH DEPT.APPROVAL
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`0' `,P27P. ',,,,ELL. C \
t ',goy N � a, � i' STATEMENT OF INTENT
t THE WATER SUPPLY AND SEWAGE DISPOSAL
C. t i 0
t -= l , SYSTEMS FOR THIS RESIDENCE WILL
s NI ! CONFORM TO THE STANDARDS OF THE
rte /// / ,� p TEST HC LE , f 0 SUFFOLK CO. DEPT. OF HEALTH SERVICES.
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APPLICANT •
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4 SERVICES - FOR APPROVAL FOR
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6.64.44.30-;-Y. /90.4I .?` 30 s7•1(d '6/7C-
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