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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK v •
ac P.O. Box 1179
U'' Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � ���' Fax (516) 765-1823
MARRIAGE OFFICER etif • ," Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 7®1 �1O
FREEDOM OF INFORMATION OFFICER +�� ��r�O
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1126 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. 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, AND PROPERTY LINES. PROVIDE COVER AS REQUIRED IN DRIVEWAY.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner POTDEVIN, ROBERT
Mailing Address 1 4300 PECONIC BAY BLVD.
City St Zip LAUREL NY 11948
Property Address 1 4300 PECONIC BAY BLVD.
City St Zip LAUREL NY 11948
Tax Map No. section 128.00 block 4 lot 23.000
Cross Street DELMAR DRIVE
Building Permit Number Cross Reference:
Issue Date: 5/11/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY ; . ''4 . Town Hall, 53095 Main Road
TOWN CLERK O irs T P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS �.` Southold, New York 11971
MARRIAGE OFFICER U® 0- .4 Fax (516) 765-1823
�,y®1 a1D rid Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK .
TOWN OF SOUTHOLD
MAY — 2 19941
994 Li
TO: Southold Town Building DepartmentBLDG.
FROM: Linda Cooper, Southold Town Clerk's Off, ,:._ T° -i1 alp
DATED: May 2, 1994
Transmitted herewith is a copy of application No. A1165 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
t Peconic Cesspool for Robert Potdevin �w�f-`9_ 3 // .
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 followiinn recommendation: .‘t)11APPROVE - G/ 01"14951
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DISAPPROVE - f®5).
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OFFICE OF THE TOWN CLERK ,,,'",,,,-
Town of Southold .�' C,U�Fa(I�
Judith T. Terry, Town Clerk ��' ®l/t.A Application No. /K�s
Town Hall, 53095 Main Road ; Construction
P. 0. Box 1179 ; c ,
Southold, New York 11971 ct� / Alteration
Telephone $10.00 - Residential rt
(516) 765-1801 _ 1 '�,
� $25.00 -Non-Residential
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
YA/SV/f,V
APPLICANT NAME: 4
APPLICANT ADDRESS:
SEPTIC CESSPOOL L/
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCT! OR ALTERA ON:,
OWNER OF PROPERTY:
OWNER MAILING ADDRESS: .7-y j -� /i%'..... .
7/ , 9
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 4:72/1-- 96 5
TAX MAP NO. : Section /lg Block l Lot 2-5
GROSS STREET: deZfri/v/-1--
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of ApplAW t
RECEIVED BY: � Q_ j
Town Clerk's Office
DATE: 0y al 9 Pce-
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