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JUDITH T. TERRY
,Z%:' Town Hall, 53095 Main Road
TOWN CLERK : ® P.O. Box 1179
V W 1 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = . ,, - Fax (516) 765-1823
MARRIAGE OFFICER '`-‘02'` Tsc® 0Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER = (a i Pre
FREEDOM OF INFORMATION OFFICER +_�„,rd , 1°.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1112 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : THOMAS H. SMITH
Address 1 : 242 SOUTH KETCHAM AVENUE
City St Zip AMITYVILLE NY 11701
Descripton of Proposed Construction or Alteration
SEPTIC SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF# R10-94-0006
Name Of Owner SMITH, THOMAS H. & BARBARA J.
Mailing Address 1 242 SOUTH KETCHAM AVENUE
City St Zip AMITYVILLE NY 11701
Property Address 1 BANKS STREET
(LOT 3)
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 97.00 block 3 lot 18.008
Cross Street EUGENES ROAD
Building Permit Number Cross Reference:
Issue Date: 4/19/94 Judith T. Terry
Southold Town Clerk
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0 i '.9,„ / / 1 2. ..
,' ® Town Hall, 53095 Main Road
JUDITH T. TERRY � � :
TOWN CLERK : ® P.O. Box 1179
U' �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ":04.,.. '�; Fax (516) 765-1823
MARRIAGE OFFICER _ .��' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ®1 ` �'
FREEDOM OF INFORMATION OFFICER ---.�i,,,,, ���'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
' DCitI0WN _ ._1
TO: Southold Town Building Department i f
FROM: Linda J. Cooper, Southold Town Clerk's Off'ce
DATED: April 1, 1994 ; 111110.DEPT
TOWN . .. OLD I
Transmitted herewith is a copy of application No. 1148 for a Cesspool/
Septic Tank Construction Permit submitted by:
Thomas H. Smith •
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 mendations:
APPROVE
DISAPPROVE
Comments: -7/� jam,,. �d< ® 7 t2C
E
APR 1 8 1994 Signaturdr
-
ion Cl® �C� 99
Date
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OFFICE OF THE TOWN CLERK OC FDLr
Town of Southold _ ".- c*
Application No. 7C/ �,(�
Judith T. Terry, Town Clerk , F
Town Hall, 53095 Main Road • o ',;.. x Construction L�
P. O. Box 1179 : ` '':"= '
Southold, New York 11971 O'`�lo .� �O��J Alteration J
`_l ! Residential
Telephone •
-1
(516) 765-1801 "' 7 'Non-Residential
TOWN OF SOUTHOLD ,,
,
SOUTHOLD WASTEWATER DISPOSAL DISTE CT `
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL••
Permit No. •
Fee •$
DATE 442// /./ /99`//
APPLICANT NAME: -2,:jpmz ' X/ ''7/7V
APPLICANT ADDRESS: ,W/77,P. c5T3, ��r G,5,9, /9've
4/m/7 y /� (�1//� A /770/
SEPTIC CESSPOOL �! /7--y
/
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION ,
A/exy' e?,*(7 i"72�o..-776.71/ „,02/"-,;i77 ,Zesi.C} rc.6 -5--
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY -4-p�yJ -4" eg72,e5,9/2.4 ..7e---,57/1/5;7-3/?-N
OWNER MAILING ADDRESS: c292 , TG�i/,y �.�
A /7yv,7/... ivy //70/ ,
OWNER PROPERTY ADDRESS: ,46:7- 254 3y�� 5-7,
G�›.-ch9u�
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section . 9z ®dBlock ,03, & Lot �1vP, 470g
CROSS STREET: 4,9C- � ,,e) ,
BUILDING PERMIT NUMBER CROSS REFERENCE:
,....../..‘9,-,---,,eav ,,',92-7..-e°
J�. / Signature of Applicant
RECEIVED BY: l " f G
Office DATE: //wnerk's
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�.4`"-,..•In .. ., .-, {- - ` ..-, -. .__,—_ ,_ - -- - ' . _— - -. . -- -
SUFFOLK CO.HEALTH DEPT.APPROVAL �,
i,,‘;'-',7. = _ ;MAP OF PROPERTY H S. NO
r'ir01,'t...: „ --0 i.• - - 5C1f2VEYE17. -FOR. i
4°7;` +k, I -.srAI.ANT) ..' •
I = ` • . T-OMAS 1N. t BAR- BARA
418.69 . . STATEMENT OF INTENT
.S'72;36:20•'E _ , 5M=1 T_l--N,`_ THE WATER SUPPLY AND SEWAGE DISPOSAL
i!'= ;f �\ L.'• ` .AT " SYSTEMS FOR THIS RESIDENCE WILL
k'''''''''ilk;: Z ,,• r''` '; �; r ~�/S - ?'I- -.USICHOGUE CONFORM TO THE STANDARDS OF THE
F._,,j , I PnoBtii(Fa�b = j JOD� y `` I SUFFOLK CO DEPT OF HEALTH SERVICES
e.:;‘,....•/r „ g . : • I . s / Y t 'OF SOUTfaCI..D,-N.Y. • cs1
'e,=4i,,t.,:.,? I _ - ''J;• - , ,- ,n - I 'y; 1, APPLICANT
-�,.,• ,� _.; ;.�, • e , ,�`z���s.{A P. ;;<,,,r.,r, 1< 1" ,^ I• - SUFFOLK COUNTY DEPT OF HEALTH
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.,'-;'�.•7.�., '!"" ,-.''.',41'..' �- ? .),•,} /i3 ,el*I- • '=k p 7,--. arAPPROVAL FOR
C1��,• 1Crd3• �5.1a ,r °tas Q rSvy �±'YyFjv,. m SERVICES FORFjO `
To \I•-----7 �� • -I !,__0„:„_, _S•P�PSEvnc �3� t �O CONSTRU�rI,O�V IJJT
a I`_ _ - ;RivE r_' DATE. /! _
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�fl / J. �pC•65.0 APPROVE p��
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•- �trNQ' 2 I' S54�5 ?/54� S SUFFOLK CO TAX MAP DESIGNATION
, -1 \\\\ DIST SECT BLOCK PCL
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Oy f I \\--1h 00 �7S P/018.1
t f ``ti' jJ,IZ•5 �vi. , ,96? T , OWNERS ADDRESS
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' \ AMITYVILLE id f .11701
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71SCSI 114. .... O (n�. �q�R Sw"rJr..;c...:71.1...11.1.;-1;.'",-3j UNCLE FAMILY D"JL.LLNG 0:1Y , 9G` •'T"_ a . LC,-.M� u cr;:: '-•_.,�'w
7 t99d EXPIRES THREE YEARS FROM DATE OF •APPROVEI. 1� s LT i uuew.: ` a
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— — — — AS SUQVEYED 1)EC 8,J91;; �/ i • y
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RODERICK VAN TUYL.P C. I r� , rj ,
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LICENSED LAND SURVEYORS - Y /
\ GREENPORT NEW YORK 1
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