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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® ft,
Box 1179
REGISTRAR OF VITAL STATISTICS (J2' Southold, New York 11971
MARRIAGE OFFICER
V!'� Fax (516) 765-1823
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF-SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 808 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : MARK SORENSEN
Address 1 : P. O. BOX 650
City St Zip GREENPORT NY 11944
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 10/22/91 .
Name Of Owner SORENSEN, MARK
Mailing Address 1 P. O. BOX 650
City St Zip GREENPORT NY 11944
Property Address 1 ORIOLE DRIVE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 55.00 block 6 lot 15.038
Cross Street LISA DRIVE
Building Permit Number Cross Reference:
Issue Date: 3/19/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY �' .. Town Hall, 53095 Main Road
TOWN CLERK ��� r���� P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS tO Southold, New York 11971
MARRIAGE OFFICER %M® O 4`,. Fax (516) 765 1823
e ,J, �.!' Tele r e (516) 765 1801
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OFFICE OF THE TOWN_ CLERK /J
TOWN OF SOUTHOLD ��S 0o �`°�.o. ,�
C.,?..,-:+e „ %�
To: Southold Town Code Enforcement Officer - :vim '
From: Linda Cooper, Southold Town Clerk's Office
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Dated: March 17, 1992 '°.,v
Transmitted herewith is a copy of application No. 833 for a Cesspool/
Septic Tank Construction Permit submitted by: -
Mark Sorensen .
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 X, RECEIVED
DISAPPROVE MAR 01A9?
c�LAiroWn Clary �iComments: a, -1. .. .. �. cvll � ctal�1
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Signature
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Dated
OFFICE OF THE TOWN CLERK ,,'"'"""
Town of Southold .'' , �FFD(x
Judith T. Terry, Town Clerk �� Q� �Gy: Application No.
Town Hall, 53095 Main Road �� Construction
•
P. O. Box 1179 t v '; rn Alteration
Southold, New York 11971 •cr' 4.
Telephone \y!,>3' - � �' $10.00 - Residential
(516) 765-1801 -�el
' $25.'00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ (1:5----
DATE
1DATE `? -7 (1'7 _
APPLICANT NAME: /v1(-2k-
APPLICANT
{4 (cAPPLICANT ADDRESS: 1-901(3.0 X 6,�O g (fir£ it/ ol2T /( Y / f/ y q:/
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION qb(9Gj ,
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: /4A-P(i s'054L7--/
OWNER MAILING ADDRESS: rO X Cs) G-lett'Npow i N1 u, 7,q' -(
OWNER PROPERTY ADDRESS: ' �2� bL,= .na t`Vl=
TELEPHONE NUMBER OF CONTACT PERSON: -L - ( ( (
TAX MAP NO. : Section C5 Block C Lot
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
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Sign t1e of Applicant
RECEIVED BY:
Town Clerk's gficEe V ED
DATE: MAR
44.4992
Southold Town Clerk
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SUFFOLK CO.HEALTH DEPT.APPROVAL 1
• H S. NO \
i Ja . - , ,- - ;', JI;Ff Of.� LO�1�'1lY - 1
' _ ' • s yf'f. 0 '-,EAL H
�� ,-i RIvr,IHC A�.N 7 11901 ti
�i� 0Qc„„� Dec 19 2 or PH '91
_ STATEMENT OF INTENT
Lia �.,-_�� It/l,a `Q� +�.Q ]�35 THE WATER SUPPLY l-,ND SEWAGE DISPOSA{.
✓.2� + ) _� I� _ /�� _ SYSTEMS FOR TH"S SIDENCE WILL
1'b% ALF HIC7l-->./ _l1V r• M AD0IN5 CONFORM T. THE ,S'A-DARDS OF THE
L B,,�Q¢�i- � fY ' __-.._.. _ __�� _ _ SUFFOLK %:t� '�EPT • HErALTH SERVICES.
4 a$�Z S. 24d _ ?,4;,, % _ __r'1>�N _ (SJ .ig , !.t vu`,r_F
AP-' ICAN
8p� cam -_ —.� (.5uF*�o�c.rt"Coc1iITV FIC.Ea 1-401P,# 8910
� 98 ' AT ' SUFFOLK COUNTY DEPT OF HEALTH
a I /
SERVICES - FOR APPROVAL FOR
�=. E rse��a c SDIJY'NQL _l�l. Y CONSTRUCTION ONE`
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7 1 .5UI�YEYEO �'lJQ DATE l` f t
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.. , ') p y-� r/ �7 r _h _ H.S.REF.NO. x17 - � •
M i° i ° iv1: k 50ES��. /V APPROVED la6/�/..11 ..O✓\ )i' -i �- •_-1. N '.L ) '6./4f.5'��
' I°"\4V4.14/-1-11
1 `MI SUFFOLK CO TAX MAP DESIGNATION.
1 --4-L';,` I ) ' DIST SECT BLOCK PCL.
oCRC.E= 40'-l" ' rdao 55 6 15.38
_� ho OWNERS ADDRESS:
t
1 P.o. Sox m50 - --
Gr•ZEIONI:'oa,T; r.1. 3 1144
i3: 135; h (g,
/*:
h G] =MOr7tJr+7eh1i' DEED L. .v/,9 P.
B = st.z.t�3TEST HOLESTAMP- `o E/e vafions�y�) refer to moorrvi Sea /ova/ (JG VD..-
'''y• '4.
M.8 9454'10-14/.•- 124 50 3- FEEING 0�PP�tO �� ;
of v
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.(//, F.. Godar” SING\AnILG, , �FR ,,,,,._.-0(vac a n 79 E.��Ip 1�S I Y'+ n t.q F'
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SEAL
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- , ' Sarveyed Dec.s, 1991 ,
RODERICK VAN TUYL•P.0 '-:•& h=-
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LICENSED LAND SURVEYORS —'=
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GREENPORT NEW YORK
113.:0Y3.1 POS: 3.3:23