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JUDITH T. TERRY � Town Hall, 53095 Main Road
TOWN CLERK [ 3 P.O. Box 1179
D .REGISTRAR OF VITAL STATISTICS !'
Southold, New York 11971
MARRIAGE OFFICER G 0 ���` Fax (516) 765 1823
° �s044 Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 796 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : DANIEL AND LISA JEROME
Address 1 : 45125 MAIN ROAD
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 12/10/91.
Name Of Owner JEROME, DANIEL AND LISA
Mailing Address 1 45125 MAIN ROAD
City St Zip SOUTHOLD NY 11971
Property Address 1 HORTONS LANE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 54.00 block 3 lot 18.000
Cross Street NORTH ROAD
Building Permit Number Cross Reference:
Issue Date: 1/17/92 Judith T. Terry
Southold Town Clerk
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JUDITH T. TERRY ;, Town Hall, 53095 Main Road
TOWN CLERK Z a ": P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER 1:20 O 'Nr
Fax (516) 765-1823
_, �jr,® *�®�0�� Telephone (516) 765-1801
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OFFICE OF THE TOWN_ C �' 7 ,
TOWN OF SOUTHOLDJAN A a
To: Southold Town Code Enforcement Officer;` ° C._,'^' a; e ;- ,; ,,
From: Linda Cooper, Southold Town Clerk's Office
Dated: January 8, 1992
Transmitted herewith is a copy of application No. 817 for a Cesspool/
Septic Tank Construction Permit submitted by:
Daniel & Lisa Jerome ,
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 JAN 17199
* * * * * * * * * * * * Tim Cleric SOHO
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE x
DISAPPROVE
Comments: qt„ 4.a. e. 41.. IV% q zat•LkQsts4-
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Signature
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Dated
OFFICE OF THE TOWN CLERK �,,,'",,,,
Town of Southold .''� \VULA'
� %"),'c' 0QG Application No.
Judith T. Terry, Town Clerk •
Town Hall, 53095 Main Road . Construction
P. O. Box 1179 ; � •, r, t
® Alteration
Southold, New York 11971 '_ �•`
Tele hone ;yO - Q��i1 $10.00 - Residential c/
(516) 765-1801 '..7®1 Alt W '�
�
�` $25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $/b o_
DATE bekm R \ 92
APPLICANT NAME: So- T c o rn�
APPLICANT ADDRESS: -(
SEPTIC CESSPOOL ✓
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY,: o.r1\-eX
OWNER MAILING ADDRESS: lAaSo
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: Lo-S--
TAX
ojTAX MAP NO. : Section E �. Block Lot 1$
CROSS STREET: )c)„�A.
BUILDING PERMIT NUMBER CROSS REFERENCE:
)11114,
Signatur= of , pplicant
RECEIVED BY:
Town C1erk's Office •
DATE: 2—
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, . SUFFOLK CO.HEALTH DEPT APPROVAL ,.
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,STATEMENT OF INTENT
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Ki 4'7a 07 20 E. 183.91 1.e:A/./N CV: SOUTI-IOLD KIY, SYSTEMS FOR THIS RESIDENCE WILL'
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