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JUDITH Town Hall, 53095 Main Road
JUDITH T. TERRY ►�
TOWN CLERK Fri P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS � ��1 Southold, New York 11971 Fax (516) 765-1823
MARRIAGE OFFICER _0 %.0,� 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. 892 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : BRIAN DICKERSON
Address 1 : 2575 SKUNK LANE
City St Zip CUTCHOGUE NY 11935
Descripton of Proposed Construction or Alteration
REPLACE COLLAPSED CESSPOOL.
APPROVED AS SUBMITTED. PLACE NO CLOSERE TO WATER SUPPLY THAN EXISTING
REMOVE COLLAPSED POOL AND DISPOSE AT LANDFILL. DO NOT BURY.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner DICKERSON, BRIAN
Mailing Address 1 2575 SKUNK LANE
City St Zip CUTCHOGUE NY 11935
Property Address 1 SAME
City St Zip 0000
Tax Map No. section 97.00 block 4 lot 13.000
Cross Street EUGENE'S ROAD
Building Permit Number Cross Reference:
Issue Date: 8/10/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY .•C'. Town Hall, 53095 Main Road
TOWN CLERK t O T P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS .11") � Southold, New York 11971
MARRIAGE OFFICER y0 � Fax (516) 765-1823
=_�,yo �1D0'.
�� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department JUL. 2 9
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: July 29, 1992
Transmitted herewith is a copy of application No. A916 for a Cesspool/
Septic Tank Construction Permit submitted by:
Brian Dickerson •
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: j) v.A Clolasu.. 04
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Signature
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OFFICE OF THE TOWN CLERK ,,'""""'
Town of Southold X01. cOV ULxe•O Application No. ,[�G�
Judith T. Terry, Town Clerk ,40'�� . Gy ` ��
Town Hall, 53095 Main Road Z G Construction
P. O. Box 1179
Southold, New York 11971 %c:72 Alteration
-%0 ���' $10.00 - Residential
Telephone - 40
(516) 65-1801 .. .1 P ��' , $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 249
APPLICANT NAME: ;4-M/(/ 1)/(4/- t /7
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APPLICANT ADDRESS 4' ,252 t5hi/K'
i� //75
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
/9/74r- ex /�`7LfAl S Ste' k
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: vh t7
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 72171'57Y/
TAX MAP NO. : Section 97 Block IA Lot (3
CROSS STREET: r n r 'S 7p14
BUILDING PERMIT NUMBER CROSS REFERENCE:
RICEIVED
JUL 2 91992
Signature of4?-'%4'Mpplicant
Town Oak Whole •
RECEIVED BY: , i �j4/110
• CI rk s .ice
DATE: -
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