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ELIZABETH A. NEVILLE �$ ,* y ; Town Hall, 53095 Main Road
TOWN CLERK
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�- P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
v, Southold, New York 11971
MARRIAGE OFFICER :ii1, �� �, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ‘414 Telephone�a of Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ rrr� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2839 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : MELANIE FRANCIS
Address 1 : ONE COTTONTAIL COURT
City St Zip SHIRLEY NY 11967
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-02-0114
Name Of Owner COEN, DEBRA
Mailing Address 1 372 BROOKLYN AVENUE
City St Zip BROOKLYN NY 11213
Property Address 1 5905 WESTPAHLIA ROAD
City St Zip MATTITUCK NY 11952
Tax Map No. section 113.00 block 14 lot 1 .000
Cross Street COX NECK ROAD
Building Permit Number Cross Reference:
Issue Date: 7/23/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE ti h Town Hall, 53095 Main Road
TOWN CLERK o Dy P.O. Box 1179
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yy. Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ` 4` �� Fax (631) 765-6145
MARRIAGE OFFICER ,L
RECORDS MANAGEMENT OFFICER y_Wel it;.,i. , Telephone (631) 765-1800
FREEDOM 9FF}CER - i1'� southoldtown.northfork.net
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JUN 2 A 2002 -,, OFFICE OF THE TOWN CLERK
�^f , TOWN OF SOUTHOLD
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T Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: June 24, 2002
Transmitted herewith is a copy of application No. 2942 for a Cesspool/Septic Tank Construction
Permit submitted by:
Harborview for Melanie Francis
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments:
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Signature
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Dated
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OFFICE OF THE TOWN CLERK , . vourz
TOWN OF SOUTHOLD ;' �J �QG Application Noo)cl4�,
ELIZABETH A.NEVIL LE,TOVN CLERK
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P.O.BOX i179 . }� Construction
SOUTHOLD,NEW YORK 11971 T , Alteration
s its Telephone
ire' • $10.00 -Residential 10.00
P
(631) 765-1800 ----ilk. 4',�" $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
RECEIVED
for
CONSTRUCTION or ALTERATION PERMIT JUN 2 4 2002
•
SEPTIC TANK or CESSPOOL
Southold Town Clerk
•
Permit No.
Fee $ 10 l /
DATE �r / �` J a—
APPLICANT NAME: .Melanie Francis
APPLICANT ADDRESS: One Cottontail Court, Shirley, NY 11967
SEPTIC ' CESSPOOC
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
D N-e 4 t
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Debra Coen
OWNER MAILING ADDRESS: 372 Brooklyn Avenue,
Brooklyn, NY 11213
OWNER PROPERTY ADDRESS: 5905 Weai-phal is Rnad
Mattituck, NY
TELEPHONE NUMBER OF CONTACT PERSON: Melanie Francis
TAX MAP NO. : Section 113 Block 14 Lot 1
CROSS STREET: Cox Neck Road
BUILDING PERMIT NUMBER CROSS REFERENCE:
NAT Ct vW°. -4j)cen„(LLD
Signature of Applicant
Melanie Francis
RECEIVED BY:
Town Clerk's Office
DATE:
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UNAUTHORIZED ALTERATION OR ADOITION TO THIS SURVEY IS A VIOLATION OF SECTION 721 `� ` i�j
J OF NEW YORK STATE LAW 1.
0 _ _ COPIES OFTHISSURVEY MAP NOT BEgRMI(;THEIJINgSURV O -4
Mq/�JTAic, I SorT/� ® SEAl3HALLNOiBECONSIDEREDTOBEA�/ALIDTRUEDSEALOREMbOssED J �rj
p66to��/ GUARANTEES OR CERTIFICATIONS WDICATEDHEREON SHALL RUN ONLY TOTHE PERSON FOR
� WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY,
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GOVERNMENTAL AGENCYAND -{ � "�
D TO TH E ASSIGN EES -
OF THE LENDINQ INSTITUTION GUARANTEES OR LISTED CERTIFICATIONS ARE NNOTT TRANSFERABLE IJ 0
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111 TO TO ADDITIONAL INSTITUTIONS OR SUBSEOUENT OWNERS
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APPROVED 7; ,.��-I 6-1I v f' AN;D 1
FOR MAXIMUM OF BEDROOMS '� : I
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EXPIRES THREE YEARS FROM
DATE OF APPROVAL
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