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JUDITH T. TERRY ; 4. Town Hall, 53095 Main Road
TOWN CLERK Z • P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS T . Southold, New York 11971
MARRIAGE OFFICER . V� �$ Fax (516) 765-1823
,�� �• Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 771 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : WILLIAM AND DIANE EDGETT
Address 1 : 701 HYMAN AVENUE
City St Zip WEST ISLIP NY 11795
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLIN WITH CESSPOOL SYSTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 7/30/91 .
Name Of Owner EDGETT, WILLIAM AND DIANE
Mailing Address 1 701 HYMAN AVENUE
City St Zip WEST ISLIP NY 11795
Property Address 1 200 DEEP HOLE DRIVE
City St Zip MATTITUCK NY 11952
Tax Map No. section 115.00 block 12 lot 3.000
Cross Street NEW SUFFOLK AVENUE
Building Permit Number Cross Reference:
Issue Date: 10/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY % . < Town Hall, 53095 Main Road
TOWN CLERK ,1 0 ,Zf i P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS . VI Southold, New York 11971
MARRIAGE OFFICER V0� 0�-���� Fax (516) 765-1823
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(516) 765-1801
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OFFICE OF THE TOWN CLERK )1E 0"-1:,.._-•:.4
TOWN OF SOUTHOLD
k OCTI5199
To: Southold Town Code Enforcement Officer
From: Linda Cooper, Southold Town Clerk's Office
TOW,' k
Dated: October15, 1991 "tom ---
Transmitted herewith is a copy of application No. 792 for a Cesspool/
Septic Tank Construction Permit submitted by:
William and Diane Edgett .
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.
G LEE--'4--
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE X
DISAPPROVE (� c
Comments: n., .,t.,,, d e� yin c 4tasak tAA. io elf.,
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Signature
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Dated
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OFFICE OF THE TOWN CLERK
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Town of Southold
Application No. °Y02.,Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c;`.
t
P. O. Box 117914-
� "p ��.: � ConstructionSouthold, New York 11971 . r Alteration
Telephone ��1 rt ���� Residential t/
(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 $ /b ✓
DATE /G) ' / 'Sl• �/ /
APPLICANT NAME: 6.J///1ctm f° / -7e , de-
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APPLICANT ADDRESS: 762i //4r)J,11..,)
'we s+ .7'S/,;_9, oriy // 7�S
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
4-0
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALIRATION:
OWNER OF PROPERTY: it)////(7,22 eel J)j9/2e- �O
OWNER MAILING ADDRESS: 7G/ �—/./.
a-7.071 frii'te
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OWNER PROPERTY ADDRESS: a0d 'e es) /4/e- •U/'/ve
TELEPHONE NUMBER OF CONTACT PERSON: ‘,5- '7--f953
TAX MAP NO. : Section / /.1"-- Block / 2- Lot 3
CROSS STREET:A/EVel S6/.
BUILDING PERMIT NUMBER CROSS REFERENCE:..
Signature o` Applicant
•
RECEIVED BY: e
Town Jerk's Office
DATE: ' / 7
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1 SUFFOLK CO.HEALTH DEPT.APPROVAL
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.... .L STATEMENT OF INTENT
F �� p1PE 'µ / J `� l *.�y , 0 THE WATER SUPPLY AND SEWAGE DISPOSAL
Ol '� w` ''^"'r' " W SYSTEMS FOR THIS RESIDENCE WILL
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}`.� 8 O6104,23,g, S. �, CONFORM T THE STANDARDS OF THE
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CL _ �', .. - - .- __ :� _ Ci) SUFFOLK CO. TAX MAP DESIGNATION.
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N�O?.'�, .,o,t J 1 -'7 - ,o. X 3 OWNERS ADDRESS: 6.ileg✓E12 L. f/hvL T/r'
. it .� �,.k , N �141 �� �� F! �.< i'��i_:_!v LA,.:,E,_
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wELL+ :� TEST HOLE ..-..STAMP
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1:S' WELL COVENANT REQUIRED ! "� aaowr,
Sf+NCY LOAM
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