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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 ts .�� Fax (516) 765-1823
MARRIAGE OFFICER r Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 1fir•'
FREEDOM OF INFORMATION OFFICER . � ��r�'��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1239 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ROBERT BOGER
Address 1 : WILLOW POINT ROAD
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. #R10-94-86
Name Of Owner PILLEPICH, A. & M.
Mailing Address 1 44 LILLIAN COURT
City St Zip RAMSEY NJ 7446
Property Address 1 COLUMBIA ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 79.00 block 6 lot 10.000
Cross Street LIBERTY LANE
Building Permit Number Cross Reference:
Issue Date: 11/15/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY % Zft. 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 ®
RECORDS MANAGEMENT OFFICER -_4,®1 • •1' Telephone (516) 765-1801
FREEDOM OF INFORMATION OFFICER �
OFFICE OF THE TOWN CLERK N'
TOWN OF SOUTHOLD — -, @ a
Il _NOV. Slid
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office = " _ BLDG.DEPT. _ -->
_LL
TOWN OF_SOUTHOLD
DATED: November 2, 1994
Transmitted herewith is a copy of application No. 1285 for a Cesspool/
Septic Tank Construction Permit submitted by:
Robert Boger for A. & M. Pillepich •
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
DISAPPROVE
Comments: cf, 0
Signature
// fa,
Dated
OFFICE OF THE TOWN CLERK c§)VFU1J
Town of Southold F • Application No. 4-9rr-
-
Judith T. Terry, Town Clerk f
Town Hall, 53095 Main Road o Construction
P. O. Box 1179F •
Southold, New York 11971 ® O�vJ Alteration
Telephone
0,14 , 1 Residential
(516) 765-1801 "'
`,Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTkICT
,. zt
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL`'
Permit No.
Fee $
DATE /�/2/f
APPLICANT NAME:
APPLICANT ADDRESS: a/GGau/ -6/r, ev, j��I4,22 4/7• //f7/
SEPTIC 'I CESSPOOL v
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
e S/0 64/1 - / / G—C L rA (L ./
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: AL /9 f2/L 7/C/
OWNER MAILING ADDRESS: 271g N,Pc
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OWNER PROPERTY ADDRESS: /GU/d7 /7} to ,_ Z/43E,/e Z pyz.
- E7rd-7-*(-d /) 4774
TELEPHONE NUMBER OF CONTACT PERSON: -7�
TAX MAP NO. : Sectio a 7? Blo 6 Lot /d
CROSS STREET: ' wr�
BUILDING PERMIT NUMBER CRO' S REFERENCE:
Ale
Signature of App • ant
RECEIVED BY: .W
,Town Clerk's Office
DATE: 1/ "i— l `f
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s�8oz7,�,�� y 13750' SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
lI '` FOR APPROVAL OF CONSTRUCTION OF
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Single Family Residence Only
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