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JUDITH T.TERRY C ` Town Hall,53095 Main Road
TOWN CLERK t/3 Z P.O.Box 1179
.F Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER y� 0�01. Fax(516)765-1823
/
RECORDS MANAGEMENT OFFICER : 41l jig as11 Fax
(516)765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1391 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : MORRIS CESSPOOL SERVICE INC.
Address 1 : 02 7‘, 21 YENNECOTT DRIVE
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
ADDITION OF AN OVERFLOW POOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES. EXCAVATION
INSPECTION REQUIRED.
Name Of Owner KIERSKY, SANDRA
Mailing Address 1 620 ROGERS ROAD
City St Zip SOUTHOLD NY 11971
Property Address 1 620 ROGERS ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 66.00 block 2 lot 35.000
Cross Street ARSHAMOMAQUE AVENUE
Building Permit Number Cross Reference:
Issue Date: 9/18/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
2°
JUDITH T.TERRY ` o= d •• Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
Ply t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1 Fax(516)765 1823
MARRIAGE OFFICER y�IJ a�1
RECORDS MANAGEMENT OFFICER .( * `t►,• 1�1
d Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER '�.���� ,•i"
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED: September 15, 1995
Transmitted herewith is a copy of application No. 1443 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Morris cesspool for Sandra Kiersky
Please review the application and location map and advise if this office may
issue the permit.
Please complete the form below and return it to this office.
Thank you.
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the follow' g recommendation:
APPROVE
DISAPPROVE -
COMMENTS: Maintain required setbacks from adjacent wells,
buildings, property lines and water bodies. EXCAVATION INSPECTION
REQUIRED.
-�•. e—
1.
Signature 9
/5-
Date
Date
--.-- ..
OFFICE' CSF THE TOWN CLERK ,,,,,�'-
Town of Southold � 01./
Judith T. Terry, Town Clerk �� Application No./Wj
Town Hall, 53095 Main Road Construction
P. O. Box 1179 *+ ; Alteration v
Southold, New York 11971 ;On
Telephone
‘,..00:„ $10.00
�,' $10.00 - Residential
(516) 765-1801 : 11 , s'�+ $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 r fJ / c
APPLICANT NAME:
APPLICANT ADDRESS: 22‘0 ' y, . ' D/
SEPTIC CESSPOOL--1
DESCRIPTION OF PRO OSED 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: Sm74,-/J .-e.e r(eiat0
OWNER MAILING ADDRESS: 20 A9
decf
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 5 _....Z57)6
TAX MAP NO. : Section 6 Block 2, Lot 3>
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
--)--N.°'71/1//‘jignature oApplicant
RECEIVED BY: Q
Towf��P Office
DATE: -SEP 1 5 1995
Town Clerk South*
,4044?-40