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ELIZABETH A.NEVILLE �o _ �d: Town Hall, 53095 Main Road
TOWN CLERK ; P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ; Southold New York 11971
MARRIAGE OFFICER w � �1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �_ 9-4( .r �� ��,i Telephone (631) 765-1800
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. 2521 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : RAYMOND DICKOFF
Address 1 : PO BOX 696
City St Zip AQUEBOGUE NY 11931
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 #R10-00-0268
Name Of Owner VRATNY, MELINA
Mailing Address 1 PO BOX 646
City St Zip MELVILLE NY 11747
Property Address 1 175 UHL LANE
City St Zip EAST MARION NY 11939
Tax Map No. section 15 block 5 lot 24.011
Cross Street RYDER FARM ROAD
Building Permit Number Cross Reference:
Issue Date: 3/02/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
1 ,
FEB 216 2OO ///�SUFFOur
ELIZABETH A.NEVILLECLERK-- t���_ �yJ°.�: Town Hall, 53095 Main Road
TOWCLERK-- ; y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �� y � �1�' Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = ®1 .��®���� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ i"
•.0.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: February 26, 2001
Transmitted herewith is a copy of application No. 2609 for a Cesspool/Septic Tank Construction
Permit submitted by:
Raymond Dickhoff for Robert& Lucille Kollmer
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:
Signat e
c=1A2 -7 /0
Dated
a' OFFICE OF THE TOWN CLERK �''s�FI 146CSG
TOWN OF SOUTHOLD � Application No. .(odf
ELIZABETH A.NEVILLE,TOWN CLERK
P.O.BOX 1179Construction l�
SOUTHOLD,NEW YORK 11971 : p 6G ; Alteration
Telephone a� �$ $10.00 -Residential
(631) 765-1800 *1 ' $25.00 -Non-Residential
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee .$
DATE /2a/
APPLICANT NAME: 4:/ i /9 ®/C4/Y7 c '
APPLICANT ADDRESS: ,fir ‘76
/9aaf/5&6-a/ //tW/ •
SEPTIC CESSPOOL C
DESCRIPTION OF PROPOSED/� CONSTRUCTION OR ALTERATION
✓/ EGL/r
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: left/ Szkir//(2- k01//iiia (*/c.-Et)
OWNER MAILING ADDRESS: a54s U flksLArc-
OWNER PROPERTY ADDRESS: Q 6/Z/fi' 7` t P 4-(7
k-1C
Aro--sl-
TELEPHONE NUMBER OF CONTACT PERSON: 7.22--,S�/O
TAX MAP NO. : Section /MO Block yr Lot (1 —
CROSS STREET: aft/ 1 6 - /l� 1 Aon
BUILDING PERMIT NUMBER CROSS REFERENCE:
7
Sig re of Applicant
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RECEIVED BY: 1h —/
Town Clerk's Office
DATE: a/ (0. �(�
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...',.........0.....i...i7, ' _______________________
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NUMBERS- REFER TO NAP OF ORIENT BY THE (-) AREA QF ks .
SECTION THREE' FILED IN, THE SUFFOLK --, C P. . . .
NTY CLeRk'S-- LIFFiCE"ON OC , 16, 1974 AS
,,i ,) SURVEY OF PROPERTY
, .
LOT 153 AT ORIENT
(D VEL vELL 15
LING) (DWELLING) TO PIN OF SO-UPHOLD
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wELL i5o,÷ 0'+
SUFFOLK COUNTY, NEW YORK
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211,00' , I OE I EL 21 3' .
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EL 23.0' N 88'26`00' E i ,
150'+
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FE VDOD FENCE SCALE: 1"=40'
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Ins ,f!Ckinitttle:'' ,wtek" the STANDARDS FOR APPROVAL ,.,m
1'-C,ON'S Mj710k [It: e•SUBSURFACE SENA/AGE —,
ticj$.:-'At4• OVE:1,4 FUR SINGLE- FAMILY RESIDENCES :..---
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I wilt '40410 by the 'coriditiohs set 'Forth therein and , . .\tOF Ntiv rn 1-;
'tle ''=0e:riq'tt).,TtO cOnstruct. '‘‘'" 1;) :_-,37-.) =
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tlQi,CO3t1619 z af we-its and cesspools shown hereon ar.e
if _ .1-04/ , i-pi..1 , 6.44--N,Y.S. LIC, Na 49618 ..
)1.4 fl*Ick .O10:ierAitt.tiorts and or elQta obtained from others..
ANY ALTERATION OR ADDITION TO THIS SURVEY- Is A VIOLATION r "E II MI*, 'U *I YORS, P.C.
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• , , ,, , , , nr- L.-rTIT7At in fir 714r iur-0 YFIPie c 747 X" .r ntirarrrnv 1 A Id C. (A n.-•1 A 5 -A . Pn 4X.,( 1) 75-1797
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