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ELIZABETH A.NEVILLE ,� � y Town Hall,53095 Main Road
TOWN CLERK y Z 1 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER ,fi -��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = Q �a��,� Fax
(631) 765-1800
JigFREEDOM 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. 4259-R Residential X Non-Residential
Fee $ 10.00 New x Existing
Name of Owner DE SIMONE, SCOTT
mailing Address 1 41780 MAIN ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 41780 MAIN ROAD
Property Address 2
c: ty St zip PECONIC NY 11958-0000
Owner Telephone No. 631-765-3535
Tax Map No. section 86.00 block 1 lot 7.000
Cross Street INDIAN NECK LANE
Issue Date: 8/06/04 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ���`Z` 4�; Town Hall, 53095 Main Road
TO CLERK ; d 1 P.O. Box 1179
e Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �. hf
MARRIAGE OFFICER : G44_ 4 $ Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER 4k). . Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER ':O'�"" ',�`�.'� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 or Non-Residential @$25 .,c1 AXA
Application No.
Permit No. 31 14 4
Owner Name -660-7 T- Si/ 4
Owner Mailing Address
dH7&9 /
"p_e 7,:z „ 9J-8
Owner Property Address
Owner Telephone No. C .31 — 765— 3 r
Tax Map No: Section 45:4„ __ Block / Lot
_Z
Cross Street ` Wed._ (av
Please check each that applies: New Construction / 61.14.,Alteration to Existi8'System `N/
Residential___�!Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Signat. - of Ap. ' ant Date
Received by:
01 eo
ELIZABETH A.NEVILLE h• Town Hall,53095 Main Road
TOWN CLERK C3 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS p �t� Southold,New York 11971
MARRIAGE OFFICER . !! Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =; ®� ��®!!� Telephone(631) 6b-1800
FREEDOM OF INFORMATION OFFICER ,,►°� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
January 29, 2004
Scott DeSimone
41780 Main Road
Peconic,NY 11958
RE: SCTM#86-1-7
Dear Sir:
Enclosed herewith is the Construction, Alteration or Modification Permit for a Septic
Tank/Cesspool System for which you applied.
AFTER the system is installed but prior to being used, an OPERATION PERMIT IS
REQUIRED. The operation Permit is issued by the Southold Town Clerk's Office. The fee is
Ten Dollars ($10.00) for a residential system and twenty-five dollars ($25.00) for a non-
residential system. Your check should be made payable to the "Southold Town Clerk". An
application form is enclosed. Please complete the requested information and return the
application, proper fee, and LOCATION MAP (map must indicate the location of the
cesspool(s)/septic tank(s), giving approximate distances in feet from any buildings to the pools
and distances between the pools.
Should you have any questions concerning this matter, please do not hesitate to contact this
office.
Very truly yours,
%!('lam- \'Y
Lynda M Bohn
Account Clerk
Enclosures
-61%
ELIZABETH
ELIZABETH A.NEVILLE *d Town Hall,53095 Main Road
TOWN CLERK y a P.O.Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold,New York 11971
MARRIAGE OFFICER -4//)
j� �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Ol dao��� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER '� ,,.���, southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3114 R Residential x Non-Residential
Fee $ 10.00 septic x Cesspool
PERMIT ISSUED TO:
Name : SCOTT DESIMONE
Address 1: 41780 MAIN ROAD
City St zip PECONIC NY 11958
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR ADDITION TO ONE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-03-0118
Name Of Owner DESIMONE, SCOTT
Mailing Address 1 41780 MAIN ROAD
City St Zip PECONIC NY 11958
Property Address 1 41780 MAIN ROAD
City St Zip PECONIC NY 11958
Tax Map No. section 86.00 block 1 lot 7.000
Cross Street INDIAN NECK LANE
Building Permit Number Cross Reference:
Issue Date: 1/29/04 Elizabeth A. Neville
Southold Town clerk
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