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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK p T P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS � `�`
,' Southold, New York 11971
MARRIAGE OFFICER ;y0�` ��0�'••� Telephone Fax l 5
(516) 765-1801
411OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1024 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : JAMES B. GIVEN IV
Address 1 : 159 OLD HARBOR ROAD
City St Zip NEW SUFFOLK NY 11956
Descripton of Proposed Construction or Alteration
ADDITION OF AN OVERFLOW TANK TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. EXCAVATION INSPECTION REQUIRED. CALL 765-1802
FOR AN APPOINTMENT.
Name Of Owner GIVEN, JAMES B. IV
Mailing Address 1 6168 COPPER CIRCLE
City St Zip ROANOKE VA 24019
Property Address 1 159 OLD HARBOR ROAD
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 117.00 block 3 lot 4.002
Cross Street NEW SUFFOLK AVENUE
Building Permit Number Cross Reference:
Issue Date: 7/14/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE 'OF THE TOWN CLERK .,'""""'--
Town of Southold .�'�� fWir
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Application No. /o3
,
Judith T. Terry, Town Clerk 's
Town Hall, 53095 Main Road ; Construction
P. O. Box 1179 = 6m
Alteration
Southold, New York 11971 t.n
Tele hone 1-20,°4., �O�''�� $10.00 - Residential `�-
(516) 7p65-1801 -. "1 4 %, o' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME: .J(.1_Y1'VE'7\ fj. Gi6ein 1T
APPLICANT ADDRESS: (5c1 016t. 47L8r
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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 CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: ( vv�.� ' -
OWNER MAILING ADDRESS: (0(tC Lp(JW
R QA.0 14 \Jc < L 1U
OWNER PROPERTY ADDRESS: r S j O Id [
TELEPHONE NUMBER OF CONTACT PERSON: 73L-1 10141
TAX MAP NO. : Section (1 Block 3 Lottr-.
CROSS STREET: h� r � , / Pw-c��
BUILDING PERMIT NUMBER CROSS REFERENCE: _ L-v\ f14,0
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Sig, :tore of Alp' .nt
RECEIVED BY: (/ /a4A-^ —m(�
Town Clerk's Office
DATE: /r/ 3
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