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ELIZABETH A. NEVILLE 1�4* �Gy�; Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
OU `V 1 Fax(516) 765-6145
MARRIAGE OFFICER ` Tele hone (516) 765-1800
RECORDS MANAGEMENT OFFICER p<-1
FREEDOM OF INFORMATION OFFICER � �'� 1 '��.��� P
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2106 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : BEN & DIANE BENEDIKTSSON
Address 1 : 50 MYSTIC CYCLE
City St Zip BAY SHORE NY 11706
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 #R10-99-0083
Name Of Owner BENEDIKTSSON, BEN & DIANE
Mailing Address 1 50 MYSTIC CYCLE
City St Zip BAY SHORE NY 11706
Property Address 1 1655 EVERGREEN DRIVE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 102.00 block 1 lot 4.005
Cross Street DEPOT LANE
Building Permit Number Cross Reference:
Issue Date: 7/06/99 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE 0, �t,1 Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
• y Z • Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Ay
MARRIAGE OFFICER � 1 Fax (516) 765-6145
RECORDS MANAGEMENT OFFICER *A. 4;
Os I° Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER : .'' * ; 1
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: June 24,1999
Transmitted herewith is a copy of application No. 2194 for a Cesspool/
Septic Tank Construction Permit submitted by:
Ben and Diane Benediktsson
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 recommendations:
APPROVE �1
DISAPPROVE
Comments:
ignature
Dated
OFFICE OF THE TOWN CLERK "COMO%
TOWN OF SOUTHOLD �+1 nV Application No.4 / 9S/
ELIZABETH A.NEV11.1.F,TOWN CLERK
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P.O.BOX 1179 Z Construction '--
SOUTHOLD,NEW YORK 11971 Z
rit Alteration
• ` $10.00 -Residential
Telephone #4 tsb
(516) 765-1801 - �l 41,,x' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ act9 lDATE i`ggj
APPLICANT NAME: �n '- bIGZ.r1Q_ r-& nedl k+SSD!>
APPLICANT ADDRESS: 6D it l S71-/C_ CJ re-w
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SEPTIC CESSPOOL V
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
New n;.-S d�n cJ—
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: ��n L b1Q,Y1� I ncQL! .V-hWY)
OWNER MAILING ADDRESS: 5-0
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OWNER PROPERTY ADDRESS: /6 5-5 f Jr) V�
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TELEPHONE NUMBER OF CONTACT PERSON: 5) & _ (.01, 5-40 )./
TAX MAP NO. : Section
'Oc Block 0 / Lot q,
CROSS STREET: L-G�-r)�
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY: N----A&A..-7.4.-LarTown Clerk'sfice
DATE: /g2, y/9
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CERTFED TO:
Mono Benedictsson
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