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JUDITH T. TERR% Town Hall, 53095 Main Road
TOWN CLERIC ® ? ' P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER �9 ���' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER '^' 1 0°��`
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. 1191 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. 0. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
ADDITION OF AN OVERFLOW CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS
BUILDINGS, PROPERTY LINES, AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner RAYNIS, DONALD
Mailing Address 1 619 ROSE BOULEVARD
City St Zip BALDWIN NY 11510
Property Address 1 1750 SMITH ROAD
City St Zip PECONIC NY 11958
Tax Map No. section 98.00 block 3 lot 20.000
Cross Street INDIAN NECK LANE
Building Permit Number Cross Reference:
Issue Date: 8/29/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
7
. o ,1',' IEFOLK ((
JUDITH T. TERRY Z Town Hall, 53095 Main Road
TOWN CLERK ® rP.O. Box 1179
Er w Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 1-_v. �. ���' Fax (516) 765-1823
MARRIAGE OFFICER ` ® t
RECORDS MANAGEMENT OFFICER = '�7®1 y► go. Telephone (516) 765-1801
FREEDOM OF INFORMATION OFFICER � ����a///°
- OFFICE OF THE TOWN CLERK MM
TOWN OF SOUTHOLD _ 0_V -
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TO: Southold Town Building Department D r% ' k$
FROM: Linda Cooper, Southold Town Clerk's Office 0 tip,'` '2 '3
DATED: August 23, 1994 ei:®G.sou;pLD_._
710\1\10 C)
Transmitted herewith is a copy of application No. A1237 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
- Peconic Cesspool for Donald Raynis .
Please review the application and location map and advise if this office may
issue the permit.
Please complete the form below and return it to this office.
Thank you.
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the followinginrecommendation:
APPROVE - v
DISAPPROVE -
COMMENTS: ./L/. .,, ., ✓`t - .,` 1,;;;.
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144/14
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AUG 2 6 1994 -'gna bre
3;4l6 8 '4-
Town Clerk Southold
Date
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OFFJCE OF THE TOWN CLERK ,,,,'",,,""--. a
Town of Southold ��'� c10[11.key = Application �No. laJ
Judith T. Terry, Town Clerk ��' �� Gy
Town Hall 53095 Main Road �� = Construction
P. O. Box 1179z
p -
Southold, New York 11971 cn te4ation
Tele hone O 00,/ $10.00 - Residential [/
(516) 765-1801 .� 0'�
$25.00 - Non-Residential
• -- „_ N1•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME:
APPLICANT ADDRESS: 4/ /6”✓- r -2-,
0f . ter' .
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:
OWNER MAILING ADDRESS: &/9
OWNER PROPERTY ADDRESS: /7 8 °
1, - �
A d -
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section e Block Lot 2-6
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
c
//
Signa/ re of Applicant
RECEIVED BY:
R Ierk's Office
DATE: AUG 2 3 1994
lc wn Clerk Southold
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