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JUDITH T. TERRY :' d Town Hall, 53095 Main Road
TOWN CLERK
P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = �® Fax (516) 765-1823
MARRIAGE OFFICER �' ® � Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER = ®1
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. 1151 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ANDREW HARBIN
Address 1 : SOUTH HARBOR LANE
City St Zip SOUTHOLD NY 11971
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. SCHD REF #R10-94-0040
Name Of Owner HARBIN, ANDREW
Mailing Address 1 PISACANO, MICHAEL
520 OAK ST
City St Zip CUTCHOGUE NY 11935
Property Address 1 1150-SOUTH HARBOR ROAD
•
City St Zip SOUTHOLD NY 11971
Tax Map No. section 75.00 block 3 lot 15.000
Cross Street BAY WATER ROAD
Building Permit Number Cross Reference:
Issue Date: 6/24/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY �' < Town Hall, 53095 Main Road
TOWN CLERK ` ® ' '. P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = t Fax (516) 765-1823
MARRIAGE OFFICER _ o4Telephone (516) 765-1801
,
RECORDS MANAGEMENT OFFICER ®�
FREEDOM OF INFORMATION OFFICER 00'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: June 16, 1994
Transmitted herewith is a copy of application No. 1194 for a Cesspool/
Septic Tank Construction Permit submitted by:
Andrew Harbin for Andrew Harbin and Michael Pisacano
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.
sL
Thank you.
c 11994
w OF eS®U�y�}1®
Linda J. Cooper '6O _---
* * * * * * * * * * * *
I, have reviewed the application and location map of the project cited above
and make the following recomm ndations:
APPROVE
DISAPPROVE
Comments: S ,1,1 of Vd4 I /o.- c
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REcevED
JuN i ,4 1994Si. a ure
iOWH Clerk Southold' 9,4
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OFFICE OF THE TOWN CLERK c0FOL/r.
Town of Southold )\� CDG
Judith T. Terry, Town Clerk Application No. Ll �'
Town Hall, 53095 Main Road � ; � Sty pg Construction
P. O. Box 1179
Southold, New York 11971 $ Alteration
Residential
Telephone of ��
(516) 765-1801
Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE �.�U I'1'�. l� Vi 1 Li
APPLICANT NAME: n(,`r cAiNi
APPLICANT ADDRESS: t Spv+h • -O„P60‘r Lr ,
So ,)--)-11 ol 0O.
SEPTIC CESSPOOL
DESCRIPTIONNew
OF PROPOSED CONSTRUCTION OR ALTERATION
Lons
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION :
OWNER OF PROPERTY: hirw.),y-..e,v4 t Yr,i��c € -Pa SAS 6
OWNER MAILING ADDRESS: 52 0*1 +, C.io-I'&t-o j ,
• OWNER PROPERTY ADDRESS: ISS 5 0 Al
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s
Sou ®) I1 X11
TELEPHONE NUMBER OF CONTACT PERSON: 731 •- ➢ 3O
TAX MAP NO. : Section � Block 3 Lot
CROSS STREET: (30L.1 r,f0,4e/r
BUILDING PERMIT NUMBER CROSS REFERENCE:
CWA12/v-J C)4W141-
// Signature of Applicant
RECEIVED BY:/ , •
Town Clerk's ffice
DATE: 64' 6,7/Thr
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PLEASE NOTE (�v . --35' VN' I' is the applicant's responsibility \
maintain adequate sanitary distancwtetween all water supply and sewn
cisposal facilities. \ A
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