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JUDITH T.TERRY �, ® - ; Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER #ir ® ��� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER (4 *woe" Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,0is'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1425 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : HENRY STEFFENS
Address 1 : 225 MOUNTAIN AVENUE
City St Zip RIDGEWOOD NJ 07450
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. #R10-95-0091
Name Of Owner STEFFENS, HENRY
Mailing Address 1 225 MOUNTAIN AVENUE
City St Zip RIDGEWOOD NJ 7450
Property Address 1 4552 GREAT PECONIC BAY BLVD.
City St Zip LAUREL NY 11948
Tax Map No. section 128.00 block 4 lot 19.000
Cross Street LAUREL LANE
Building Permit Number Cross Reference:
Issue Date: 12/07/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FO(,>(r," �7
Town of Southold
�`; '• oG A lication No. ��� i5
Judith T. Terry, Town Clerk <` i Application aiT Nn;3,; rG�
Town Hall, 53095 Main Road cin t'r;* __�� X ' Construction X
P. 0. Box 1179 ' �
"� L Mkt`} Alteration
Southold, New York 11971 �' �-
Telephone -11°. )\‘°‘' Residential
X
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE November 21, 1995
APPLICANT NAME: Henry Steffens
APPLICANT ADDRESS: 225 Mountain Avenue, Ridgewood, NJ 07450
SEPTIC x CESSPOOL X
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
Construct septic tank and cesspool for residence.
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Henry Steffens
OWNER MAILING ADDRESS: 225 Mountain Avenue, Ridgewood, NJ 07450
OWNER PROPERTY ADDRESS: 4552 Great Peconic Bay Blvd, Laurel, NY
TELEPHONE NUMBER OF CONTACT PERSON:Donald Denis, Architect 722-3511
TAX MAP NO. : Section 128 Block 4 Lot 19
CROSS STREET: Laurel Lane
BUILDING PERMIT NUMBER CROSS REFERENCE:_
oP fr
,. nature of AI i :nt
RECEIVED BY: -
o n Clerk's Office
DATE: id-- 9
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