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JUDITH T. TERRY r�
+ Town Hall, 53095 Main Road
TOWN CLERK ® ' ; P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS t ��' Fax (516) 765-1823
MARRIAGE OFFICER -.. '0$ °• Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER '_$®1 10�
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. 1076 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : TORKELSEN BUILDERS INC.
Address 1 : P. O. BOX 1475
City St Zip SOUTHOLD NY 11971
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. #93-SO-16.
Name Of Owner TORKELSEN BUILDERS INC.
Mailing Address 1 P. O. BOX 1475
City St Zip SOUTHOLD NY 11971
Property Address 1 INDIAN NECK LANE
City St Zip PECON I C NY 11958
Tax Map No. section 86.00 block 4 lot 5.000
Cross Street LESLIE'S ROAD
Building Permit Number Cross Reference:
Issue Date: 12/23/93 Judith T. Terry
Southold Town Clerk
I TOWN SEAL)
6
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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 1 `' Southold, New York 11971
�,�� r Fax (516) 765-1823
MARRIAGE OFFICER ` IN.••• Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 'rrrI"i�i� �-^:�s � PE
' FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD ItilliV} is 1
1
Blouse. tycpr.
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: December 10, 1993
Transmitted herewith is a copy of application No. 1111 for a Cesspool/
Septic Tank Construction Permit submitted by:
Torkelsen Builders Inc. .
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 G'''''
DISAPPROVE
Comments: ,�„.) f ,1 /'�Ar.•/<,
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DE0 22 1893 - Signature 4
'�!oyn ei WW1 / ��>
Dated
1
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OFFICE OF THE TOWN CLERK ,^ tr,�?
Town of Southold .:,. �-
Judith T. Terry, Town Clerk ' "•.�' -t` `-r1. t '
v c.-�:
Town Hall, 53095 Main Road ~ '°'��' Application No.J( /
P. O. Box 1179 c `�
U' �':`•' �.' 71- fi Construction
Southold, New York 1 1971 TA./ n
��- Alteration
Telephone ��°
(516) 765- 1301 1 i �b 1� Residential
f; •
Non-Resides tial
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
•
•
for •
•
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME: lr®/i KLSGSL;I1, L3 V I L 0g(2S • /1L C
• APPLICANT ADDRESS: 10
^'� `75 -0007-40C.9 oi, `/ p ,
SEPTI C__CESSPOOL x
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION A.,e-1/1J
LOCATION MAP: Must be attached hereto before
permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: �LJ�LS Ern-- '
C�ti 1 t-0 b',R /rLC
OWNER MAILING ADDRESS: " 1, 060X `1173 SOOfot0`0
y /®' '7l
OWNER PROPERTY ADDRESS: .S 0A" //1/40/,f-x., .4; 2.
335, 3" 3 IL ✓ L BSc iLsJ NO ..S0 r, L .
TELEPHONE NUMBER OF CONTACT• :PERSON7los- 317 '
TAX MAP NO. : Section ap, • Block q
Lot ,j' Di 4.7.-/Orp
. CROSS STREET: L/iJLlZrj •
BUILDING PERMIT NUMBER CROSS REFERENCE:_
•
. • j
jem_A
Signature of .
Applicant
RECEIVED BY: p ' (2 / ...... ,
Town Cle •k's Office
DATE: l► /, e •
--- --------- - ---- - l {
SUFFOLK CO.HEALTH UtI'1.Arrrc�v n6,
,1.c JP P'2GPEr%TY H S NO. z
U(z'JEYED FOR \T RVEl -EN.I BUILDERS INCr
AT
c'ECONIC I STATEMENT OF INTENT
TCVJkI O SCUT HO.LD V•Y• I J THE WATER SUPPLY AND SEWAGE DISPOSAL
I SYSTEMS FOR THIS RESIDENCE WILL
--- 402-- CONFORM TO THE STANDARDS OF THE
' 4 I EPT EA TH SEaVICES.
�20P HO I o I I SUF(S ;;� �Pfee-s
2 /i PLLICA
AP ICANT
i
250.0
SUFFOLK COUNTY DEPT OF HEALTH
_� v,7 —_. - ---------- - - - FOR APPROVAL FOR
d- - — - - - -j SERVICES
d ± __. _ -- -- CONSTRUCTION ONLY _ ' �;7
+L ; DATE '—
t ,,:12 \h H.S.REF NO �� 5 II'� -.
0 QS 0 ( l i SCALE-40.1 APPROVED
o ( - _ �/ / / AREA.40,0�0 S.F
`fl - F5EPTIC
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W ti r j'•
! DIST. SECT. BLOCK PCL.
i ., '" ! 0 1000 086 4 Pio 6 •
2 Q j o j • w OWNERS ADDRESS.
U =T c a J 790 CLIPPER DRIVE
CU > 0 a° t
CU i a 2 A P.O.BOX 1475
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TOWI OATS- IN <Iy��r� 1 TR W,TITLE INSURANCE OF t.IEWYQRK,INC. w i o° •''y *pa' Gtr .l
1.s O .1r A5 SURVEYED MAR.16,1993 N ,. y '.THE
THE SUFE CO CLC�!IC'9i QI=FICE AS MAP NO_9331. ••• ti "tyro �•:
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• ------_---_ SU2VEYED_APR.27r1992 � -• ----��-°- ice. •
AMENDED-JUNE 3o I q2 �`L OUT1
_ I TOWN OF SUUTriOL!? _ LICENSED LAND SURVEYORS
n -MAR.16,I993GREENPORT NEW YORK
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