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JUDITH T. TERRY ; 0 Town Hall, 53095 Main Road
TOWN CLERK
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P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS * �1 Southold, New York 11971
MARRIAGE OFFICER ® ®�
t. � Fax (516) 765-1823
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Telephone�1� 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. 1108 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
INSTALLATION OF NEW OVERFLOW CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, PROPERTY LINES, AND BUILDINGS. EXCAVATION INSPECTION REQUIRED.
Name Of Owner KALLER, ROGER
Mailing Address 1 7895 BAY AVENUE
City St Zip MATTITUCK NY 11952
Property Address 1 7895 BAY AVENUE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 104.00 block 4 lot 24.000
Cross Street BROADWATERS ROAD
Building Permit Number Cross Reference:
Issue Date: 4/04/94 Judith T. Terry
Southold Town Clerk
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®® Town Hall,T. TERRY 53095 Main Road
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TOWN CLERK ® ' P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER e,° • st Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER '= .•i.
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK D OW
TOWN OF SOUTHOLD Ill 2 8
1111 11J
TO: Southold Town Building Department TOWISMOLD
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: March 28, 1994
Transmitted herewith is a copy of application No. A1145 for a Cesspool/
Septic Tank Construction Permit submitted by:
Peconic Cesspool on behalf of Roger Kaller
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. EXCA SAT ErQp�gi{]��aa44
M
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above -
and make the following recommendations:
APPROVE
DISAPPROVE
Comments: f � i '&.4;/ �) /4
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RECEVED
MAR 3 1 1994 Signature?
Town clerk Southold ��
Dated
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OFFICE OF THE TOWN CLERK ,,,,,,,,,,"'''-
Town of Southold ,0" Vinire'' .. -
e % _; c -, Application No. //`�i _
Judith T. Terry, Town Clerk �, y �
Town Hall, 53095 Main Road ; Construction
P. 0. Box 1179 , =U - ,=T,
Southold, New York 11971 . ' -, - I,; Alteration
Telephone ..VA. �' $10.00 - Residential 'it.
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(516) 765-1801 =_ of , $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL '
Permit No.
Fee $
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DATE a.
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APPLICANT -NAME: ,_ r ,, '�
APPLICANT ADDRESS: 40 972_ •
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED,CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
OWNER MAILING ADDRESS: 73 'r—
OWNER PROPERTY ADDRESS: .--
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section /0cC, Block . Lot i9,�
GR S STREET: a r-z---2, ,) o
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED -
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MAR 2 81994 - = 7 ,.lh' 1 /./
Signature of App,,(ant
Town Clerk Southold -
t RECEIVED BY: ..,,„4.,,_,,, , ;- //
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own`1 I-'rk': Office
- '' DATE: *EM
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