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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p r� P.O. Box 1179
Er • Southold, New York 11971
REGISTRAR OF VITAL STATISTICSV® Fax Fax (516) 765-1823
MARRIAGE OFFICER .j' ®I�� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ==7®1 i
FREEDOM OF INFORMATION OFFICER `�� �iri, ,
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1072 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1 : P. O. BOX 972
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
REPLACE CAVED-IN CESSPOOL WITH NEW TYPE.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, AND PROPERTY LINES. EXCAVATION INSPECTION REQUIRED.
Name Of Owner WOLBERT, AUDREY
Mailing Address 1 4820 NEW SUFFOLK LANE
City St Zip NEW SUFFOLK NY 11956
Property Address 1 4820 NEW SUFFOLK LANE
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 110.00 block 8 lot 15.000
Cross Street WICKS ROAD
Building Permit Number Cross Reference:
Issue Date: 12/10/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK • v T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
% Fax (516) 765-1823
MARRIAGE OFFICER ® rt
-,y®1 �1D•
_ r Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK f ;, (0.,11-,..? 1, ,,.
TOWN OF SOUTHOLD ` 1 S;s. r3,
TO: Southold Town Building Department ' DEC �'
FROM: Linda Cooper, Southold Town Clerk's Office 1_o}„, ,`::7--6{
DATED: December 3, 1993 ----- -4sU�+ OL. .a
Transmitted herewith is a copy of application No. A1106 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Peconic Cesspool for Audrey Wolbert
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.
Linda J. Cooper
. * * * * * * * * * * * * *
•
I have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE - - EXCAVATION INSPECTION
DISAPPROVE - REQUIRED
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COMMENTS: z• • ,• , , ' ..,d( _"./
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Signa re
Date /
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OFFICE OF THE TOWN CLERK ,�,''",,,,,,',--
Town of Southold �.''' � VULtr _ /
Town Clerk �' �� ��l/ Application No. /.76 'P
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Judith T. Terry, � �, _ y�. —
Town Hall, 53095 Main Road � (: = Construction
' P. 0. Box 1179 _ 'm
Southold, New York 11971 % VI , Alteration
Telephone ,�p4, �O�i'� $10.00 - Residential 1--
(516) 765-1801 --- '1
$25.00 -Non-Residential
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE /1 f
APPLICANT NAME: ,.-e-e.. "714.-z., , 1s ,1 'y d-
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APPLICANT ADDRESS: /4e 4.0., 9iz_-
SEPTIC
CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTR CTION OR ALTEAlTION:
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OWNER OF PROPERTY: 01./ ; ' ; " �� /�
OWNER MAILING ADDRESS: 'W %-a , - i
-77.4Q-4.). 9 —
OWNER 'PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX,MAP NO. : Section Ad Block V Lot
CROSS STREET: /1"' c "1cl'el
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BUILDING PERMIT NUMBER CROSS REFERENCE:
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Signature of Appl' t
RECEIVED BY: „ COLeli,--
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To n Clerk's Office
DATE: 'Z/q -j
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