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JUDITH T. TERRY- Town Hall, 53095 Main Road
TOWN CLERK : ® rP.O. Box 1179
U' W Southold, New York 11971
REGISTRAR OF VITAL STATISTICS V® Fax (516) 765-1823
MARRIAGE OFFICER =__�'/® ® .r Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER �e
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. 1155 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : MORRIS CESSPOOL SERVICE
Address 1 : 2760 YENNECOTT DRIVE
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
ADDITION OF AN OVERFLOW TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS
BUILDINGS, AND PROPERTY LINES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner PROVENCHER, WILLIAM
Mailing Address 1 P. O.BOX 1749
City St Zip SOUTHOLD NY 11971
Property Address 1 53830 ROUTE 48
City St Zip SOUTHOLD NY 11971
Tax Map No. section 52.00 block 2 lot 18.000
Cross Street BEVERLY ROAD
Building Permit Number Cross Reference:
Issue Date: 6/28/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
6n $ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ®Y® Fax (516) 765-1823
MARRIAGE OFFICER ' '' ® to�
Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER _4p®1 ,•
FREEDOM OF INFORMATION OFFICER r��'.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
DATED: June 27, 1994
•
Transmitted herewith is a copy of application No. 1201 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Morris Cesspool for William Provencher
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.
inda J. Cooper
* * * * * * * * * * * * *
I
have reviewed the application and location map of the project listed.
above and make the following recommendation: Wit�Oy® =
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APPROVE - M
DISAPPROVE - 5,
COMMENTS: 5 e,, '
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Signat re
Date J -
OFFICE OF THE TOWN CLERK ,, •
Town of Southold cOVULxe'D -_-
/4120Judith T. Terry, Town Clerk
Application No.
Town Hall, 53095 Main Road • Construction
f , '
P. O. Box 1179 •
Southold, New York 11971 Alteration
0 ' �' •t $10.00 - Residential
Telephone .�' -ate ��
(516) 765-1801 01 11 , ' $25.00 - Non-Residential
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE (Tee-- 2? //' ` /
APPLICANT NAME:
APPLICANT ADDRESS: I 7‘-C3 j0- V,/,/)rCp fr. / /e'
•
SEPTIC CESSPOOL 1/
DESCRIPTION WROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: ' Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION :
OWNER OF PROPERTY: �-�t/ r//Qlh )/�o eAJ�'�j�� °- 744,
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OWNER MAILING ADDRESS:
-56.4 f-d-eicP �Y
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section c2 Block 2 Lot 7e-
CROSS
tCROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
20,7//‘ /
/Signature of Applicant
RECEIVED BY: RECEIVED
Town Clerk's Office
DATE: JUN 2 7 1994 •
Southold Town Clerk
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