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ELIZABETH A.NEVILLE ,t°h'r0 Gym`.� Town Hall, 53095 Main Road
TOWN CLERK o '� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T Southold, New York 11971
MARRIAGE OFFICER ‘‘3411� Fax(516) 765-6145
RECORDS MANAGEMENT OFFICER `may*0 .0wooe� Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER =.'�' •�,i��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2144 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ROBERT L. THORN
Address 1 : P.O. BOX 373
City St Zip SHOREHAM NY 11786
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-99-0091
Name Of Owner THORN, ROBERT L. AND JANE E.
Mailing Address 1 P.O. BOX 373
City St Zip SHOREHAM NY 11786
Property Address 1 2560 OLD NORTH ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 55.00 block 2 lot 1 .001
Cross Street YOUNGS AVENUE
Building Permit Number Cross Reference:
Issue Date: 8/31/99 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
I••���SUFFO(�co i C
ELIZABETH A.NEVILLE ti h'Z`� Gym; Town Hall, 53095 Main Road
TOWN CLERK • p P.O. Box 1179
REGISTRAR OF VITAL STATISTICS t Southold, New York 11971
MARRIAGE OFFICER k / Fax(516) 765-6145
RECORDS MANAGEMENT OFFICER `� �f� 40'1 Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER ' Il *;,11
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: August 30, 1999
Transmitted herewith is a copy of application No. 2230 for a Cesspool/
Septic Tank Construction Permit submitted by:
Robert L. Thorn
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 7pi6endations:
APPROVE
DISAPPROVE
Comments:
ignatu e
Dated
OFFICE OF THE TOWN CLERK 1,! C, `{�Ll/
TOWN OF SOUTHOLD ; �l �1 QQ ' __
__
Application No.a39
Fi.I7ABETH A.NEVILLE,TOWN CLERK ►
P.O.BOX 1179 Construction ✓
SOUTHOLD,NEW YORK 11971 Z
e Alteration
Telephone O,y � ��'� $10.00 - Residential
(516) 765-1801 �l N ,,o' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Rlcernte.1%
APPLICATION
AUG 3 0 1999
for
CONSTRUCTION or ALTERATION PERMIT town ClerK buutnold
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE 4t//5T 30, 19'V
APPLICANT NAME: R(� j&-7 L , T1I0I2A/
APPLICANT ADDRESS: P O , 160X 373 S/10/2-67-/A/Y1,/1/,`/ // 766
SEPTIC CESSPOOL V
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
A/ RR61,B. -TiA L (',DNS�' crt lO)v
LOCATION MAP: Must be attached hereto before permit may be issued. C/L OF QLD
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:NU N epa I /Z "491 16
OWNER OF PROPERTY: L• L�
T �0�I2T JA,Al E E• 77402IV
OWNER MAILING ADDRESS: 0 /&O)C 373 SN6V2ENAl 1)/V'/ // 75 ,
OWNER PROPERTY ADDRESS: iO OLp A 0 :Q/1► „ if OL/
TELEPHONE NUMBER OF CONTACT PERSON: 32/ — (U 72.3
TAX MAP NO. : Section 55 Block 2 Lot / • /
CROSS STREET: L/L;_OAJ 41 , 444 Vob/NOrs 41/ 3
BUILDING PERMIT NUMBER CROSS REFERE CE:
i;ic7f-
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Signature of Applicant
lel-912%--
RECEIVED BY.
own Clerk's Office
DATE: 6I2O 75
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g11°30 20 W SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
OF
1RMTT FOR APPROVAL OF CONSTRUCTIO::I-Y,:;,t
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APPROVED /C
FOR Li;•XT1 1P:i OF. PEDROOMS
EXPIRES THREE YEARS FROM DATE OF APPROVAL
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NOTES.
„
...„.....�...::a .....,■ MONUMENT FOUND
O PIPE FOUND / / TC / . Ns O LANDOJ 'r� �:I:.F ! �.., '�''' * . ...
F�
HEDGE ::° `" �
AREA = 2.11 ACRES ..:.
JOHN C. EHLERS LAND SURVEYOR
I GRAPHIC. SCALE:I". 50' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 I
_ __ I RIVERHEAD,N.Y.11901