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HomeMy WebLinkAboutComo, Guiseppe %SUffOL,�• �� 00G ELIZABETH A.NEVILLE � y� Town Hall,53095 Main Road TOWN CLERK o P.O. Box 1179 H Southold,New York 11971 REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER 0. Telephone Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ;_ l 't�ti' Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER ��,�' southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 4254-R Residential x Non-Residential Fee $ 10.00 New X Existing Name Of Owner COMO, GUISEPPE Mailing Address 1 PO BOX 1884 Mailing Address 2 City St zip SOUTHOLD NY 11971-0000 Property Address 1 800 LAKESIDE DRIVE NORTH Property Address 2 City St zip SOUTHOLD NY 11971-0000 Owner Telephone No. 631-765-8022 Tax Map No. section 90.00 block 3 lot 6.000 Cross Street CEDAR BEACH ROAD Issue Date: 6/24/04 Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) ELIZABETH A.NEVILLE � h s' `Z`�� Town Hall, 53095 Main Road TOWN CLERK t 1 P.O.Box 1179 Va Z $ Southold,New York 11971 REGISTRAR OF VITAL STATISTICS k bv Al MARRIAGE OFFICER O .1F �� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER =y� O`' / Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER = O'� �a•''' southoldtown.northfork.net .. OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION OPERATION PERMIT CESSPOOL or SEPTIC TANK 425 q Residential @ $10/ or Non-Residential @ $25 Application No.4M Permit No. 3O61, Owner Name A/ OW. ek..55'-/.///4 /7 O Owner Mailing Address / '©,g©i /pe 4 ,S 9 GL'2 ,may //P>/ Owner Property Address c(A.2-0A/1 ific5 .A/ //o/9 1'� 1� /7,P/Owner Telephone No. ‘5/` 7‘5 / _ Tax Map No: /a-ao QQSection 90 Block 3 Lot Cross Street eL3./1, 1,..9 /P4 Please check each that applies: New Construction Alteration to Existing System Residential Non-Residential NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate building and system; give north arrow and approximate dist. •-:in feet from system to building 400e and closest road. New construction may submit cop jwith SC• .' . •. oval.) Sir- . ure of Ap e 71- Date Received by: Chris Rehm Excavation & Drainage 390 Alois Lane Mattituck, N.Y. 11952 CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER Health Department Reference Number: ,t/0 C' l C C C� Suffolk Tax Map#: Dist:/62 Sect(s): J6' Bik(s): / Lot(s): b Project Name or Address: cY029 / /1 Azo Subdivision Name & Lot#: Applicant's Name: —t� Description of System Installed: Septic Tank Volume (gallons): lG c C CJ Shape: ti Rectangular [] Cylindric 1 Name of Precast Manufacture: S �'..e , , /-ecas/ Leaching Pools Number of Pools: Diameter and Depth: Other: Attach or Sketch below the measurements from the building corners to the access covers of disposal system. I hereby certify that the subsurface disposal system, described herein, has been installed by me in accordance with the approved plans and standards of the Suffolk County Department of Health Services; and is operational. Installer Signature Date: /( ( (f/ /C} Print Name/Company a �/ Phone: a3/ 2..9i 'L 3¢ Consumer Affairs License Number: )—e 2 G/ This certification SHALL NOT be used in lieu of inspections required by personnel of the Department and may be duplicated on company letterhead,provided it contains the above information. ti�