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ELIZABETH A. NEVILLE X1414 '. " d Town Hall 53095 Main Road
TOWN CLERK l P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS l'*:4g
4. 47$t, Southold, New York 11971
MARRIAGE OFFICER : a:e " Fax�1 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ,.rr22.,, �oii� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ®� �ts' �'
OFFICE OF THE TOWN CLERK
SOUTHOLD PW rWAVEARIVASREIRTEICSIPEDSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2616 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : CHRIS RIVERA
Address 1 : 250 SOUND DRIVE
City St Zip MATTITUCK NY 11952
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 #R10-00-0112
Name Of Owner NOTIAS, PERCULES
Mailing Address 1 250 SOUND DRIVE
City St Zip MATTITUCK NY 11952
Property Address 1 675 SUMMIT DRIVE
City St Zip MATTITUCLK 0000
Tax Map No. section 106.00 block 1 lot 47.000
Cross Street CENTRAL AVENUE
Building Permit Number Cross Reference:
Issue Date: 7/24/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE �� A: Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS �'�� Southold, New York 11971
MARRIAGE OFFICER �e ::,,µ �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �__ elsNs ��®''i° Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: July 3, 2001
Transmitted herewith is a copy of application No. 2704 for a Cesspool/Septic Tank Construction
Permit submitted by:
Chris Rehm agent for Percules Dophis
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
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Dated
•, . / ,
OFFICE OF THE TOWN CLERK oil sAV UL1 2c
TOWN OF SOUTHOLD ,�' % \ CCV Application No.
ELIZABETH A.NEWT.I F,TOWN CLERK
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971 : p • r=n ; "Alteration
Telephone '*' fir: • $10.00 Residential
(631) 765-1800 ---_ �,�'' $25.00 -,Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT'
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. •
Fee .$
DATE 3 a/
APPLICANT NAME: dA''''`f /4/6,69'r - Cl
APPLICANT ADDRESS: 07c5d �ou.a�
,�
SEPTIC i CESSPOOL--
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION�R
it",.4.4.1 ---",--eff...-
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONST CTION OR ALTERATION:
OWNER OF PROPERTY: /( i.A AX,s
OWNER MAILING ADDRESS: CA /get.4"....
69‘61 --re&-e A....-1 %• Ad,114-1--.„
OWNER PROPERTY ADDRESS: 447f _Sv�.-„: 2tt
TELEPHONE NUMBER OF CONTACT PERSON: 6,Jj -o7yF 4:Fe/s/'
TAX MAP NO. : Section 10-r-v Block/ O 6 Lot Doi— 5/7
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE: . ,
s
Si ature of'Applicant
•RECEIVED BY: /4/4--
To n Clerk's Office
DATE: �/- O' 7
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_ P/O LOT #13
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RESIDENTIAL. I r BROWN LOAMY SAND •
(PUBLIC HATER) S I T.- . L A N I., 2' SM 1—
ma ; PALE BROWN
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(PUBLRESIIC WATER) `ENTIAL , iI�� BROWN AND PALE
t 00 BROWN SILTY SAND W 0
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SUPPLIED BY: ..
McDONALD GEOSGIENGE rT, �-1
�\'' ll l � I°�Fi I \`� ® `! . NOTE: MAINTAIN 5S5 SLOPE MaX.51 , BOX 1000 t—
/ i `c,� i ; �, '3'4 WI ETH 2O' of SEPTIC SYSTEM 'TOLD, NY I1a71
i x�? �� (� ••= , -TA. , stiK COUNTY DEPARTMENT F HEALTH SERVICE§(63r) 165-3677
1122-4 // / Mr LZ SI I ► :� Dr4TT=: 4/2/01
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,,I� BASED ON SURVEY BY: I— 1L
:Oi � L Z fit?!' 10o7 orb° M MSN, / :r - _ ° JOSEPH A. INGEGNO
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P.O. BOX 1x31 Z
„, ` \ / RIVERHEAD, NY 1 Ia01-Oa65 0
Q i 13� �• d \/ \/ �1 o��� PHONE: (631) X27-2090
/w / FAX: (631) 727-1'727