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JUDITH T. TERRY L ; Town Hall, 53095 Main Road
TOWN CLERK • =v rZ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ` �� Southold, New York 1 1971
A• Telephone
�� Fax (516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER �� , Telephone (516) 765-1801
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. 1254 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : CORI AND KAREN LANG
Address 1 : 1204 ROANOKE AVENUE
City St Zip RIVERHEAD NY 11901
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES.
Name Of Owner LANG, CORI AND KAREN
Mailing Address 1 1204 ROANOKE AVNEUE
City St Zip RIVERHEAD NY 11901
Property Address 1 KENNY ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 59.00 block 3 lot 33.000
Cross Street ROUTE 48
Building Permit Number Cross Reference:
Issue Date: 11/28/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
JUDITH T. TERRY ,, ` ; Town Hall, 53095 Main Road
TOWN CLERK .2E
ca P.O. Box 1179
to � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = VO �,' Fax (516) 765-1823
MARRIAGE OFFICER - �' �0 I" Tele (516) 765-1801
RECORDS MANAGEMENT OFFICER = 1 ,l
FREEDOM OF INFORMATION OFFICER , d,,"
OFFICE OF THE TOWN CLERKe2
,��
TOWN OF SOUTHOLD �� /7/
•
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: November 28, 1994
Transmitted herewith is a copy of application No. 1300 for a Cesspool/
Septic Tank Construction Permit submitted by:
Cori and Karen Lang .
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 recomme ations:
APPROVE
DISAPPROVE �y ?
Comments: SC /,(� FC,G -
Signat e /
Dated/ o
•
OFFICE OF THE TOWN CLERK cjVFF0G�'
Town of Southold ) ; Application No./3 06)
Judith T. Terry, Town Clerk .•C
Town Hall, 53095 Main Road Construction
P. 0. Box 1179 �� Alteration
Southold, New York 11971 , '.
Telephone -�l ��
Residential
(516) 765-1801 '"
Non-Residential
LTOWN OF SOUTHOLD
OR SOUTHOLD
WASTEWATER DISPOSAL DISTRICT
c(
APPLICATION
13( for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ //
DATE // 9 V
APPLICANT NAME: , c)/2_ / k, ii_e 9 A
APPLICANT ADDRESS: /Zoy A9fi,4iolte f9 , , _xi ve, _61c-.A0 x( 90 /
SEPTIC v CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION /t/c cv /.&)/1 '
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Go/2-1 KfiPe,s/ 4:-/9/1-7
OWNER MAILING ADDRESS: AO, �x lc9e3 e•--cc ?/� Gee l4,325
OWNER PROPERTY ADDRESS: vf7'. izaprj Cc'< Q s ? Z3 -A-. -�
10e-,Z . � .mac mac. , /1
TELEPHONE NUMBER OF CONTACT PERSON: 73$/- 2.6 ,5-0 off,` Z SP-- '33d
TAX MAP NO. : Section 0,5-9. Block 3 Lot 33
CROSS STREET: P--)Le.: , 78
BUILDING PERMIT NUMBER CROSS REFERENCE:
Siginapplicant
RECEIVED BY: RECJIVE
Town Clerk's Office
DATE: NOV 2 1994
TdMlll Clldc Eakin
SUFFOLK CO HEALTH DEPT. .'. • K...
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STATEMENT OF INTENt 1
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I F NKK TNEOPI�ILCS / ?ts THE WATER SUPPLY AND SEWAGE DISPOSAL.
t i/F LEVIME SYSTEMS FOR THIS RESIDENCE Wt$.L
CONFORM TO TN STAN 1
E OARDS OP TH
N 5 .2.,7'10-E.
• / 353,20 SUFFOLK CO. DEPT. Oi HEALTH SIRVICEL
—� / SCALE-50.'1. (SI APPLICANT
;� �, i 2972' . /
AR.Eik,37810 SO.FT
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., 1_ `Ip R / SUFFOLK COUNTY DEPT. OP NEALT:
rJ.MONUMENT
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N.TFR LINE 1 PROP. I \� DATE.
Cru IaOP SEPTIC H.S. F V- i7A
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2 SUFFOLK CO.TAX MAP DESIGNATION:
L 3 \\ � DIST. SECT. @LOCK PCL,.
t1 I ` . a3"2'10 w 353.06 of \
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Ll/I���[ 04F,741000 059 3 93
I I f/,A ,.. OWNERS ADDRESS:
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• 1" ,- EXCAYr'NI' r.17.1,74.!3 .1►gi TAMP .
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MAP _OF P20 PE2TY 4. x.. . �7" s.>Y uoAr% ..,.,yam.
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SURVEYED FOR S WHILE Y'DWELLNS tiQOMllI cr�.ar .ra i9
T YES$ ONLY U5IMYSILT r.aa+>'uairmusiN. � h
1) CO21 {�A(Z E N . LANG
��DATE of Appp v , a�.,. ,:
`—�- '*'r'' AT MAP AMENDED-TEST NOLE DATA•AL IG22,1994 a1s . "
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rno�� e ?� TOWN OF 5Oom4OLD / NY. SEAL
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