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ELIZABETH A.NEVILLE �'j y_A: Town Hall, 53095 Main Road
TOWN CLERK ; ti P.O.Box 1179
REGISTRAR OF VITAL STATISTICS '$ Southold, New York 11971
MARRIAGE OFFICER �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =_�®.j .A� io 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. 2536 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : THOMAS COSTA
Address 1 : 21-66 45TH STREET
City St Zip ASTORIA NY 11105
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 #R10-99-0205
Name Of Owner COSTA,, THOMAS & ANA
Mailing Address 1 21-66 45TH STREET
City St Zip ASTORIA NY 11105
Property Address 1 150 HILLCREST DRIVE
City St Zip ORIENT NY 11957
Tax Map No. section 13.00 block 2 lot 8.032
Cross Street HEATH DRIVE
Building Permit Number Cross Reference:
Issue Date: 3/27/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE �t ir
0Hall, 53095 Main Road
�
TOWN CLERK 4 a ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER : Fax Fax(631) 765-6145
vdt,RECORDS MANAGEMENT OFFICER -•.-_70.4f Al .0®p1 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: March 15, 2001
Transmitted herewith is a copy of application No. 2624 for a Cesspool/Septic Tank Construction
Permit submitted by:
Thomas Costa
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:
52/ignature
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Dated
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OFFICE OF THE TOWN CLERK , �' ULepGy
TOWN OF SOUTHOLD ,�'OD Application No.a(op!`I
RI.i7ABETH A.NEVILLE,TOWN CLERK `
P.O.BOX 1179Construction
SOUTHOLD,NEW YORK 11971 p Alteration
Telephone �y0,� �0-1,0, ' $10.00 -Residential v
(63t) 765-1800 -=y01 I �,�" $25.00 -Non-Residential
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
•
for
CONSTRUCTION or ALTERATION PERMIT ;
SEPTIC TANK or CESSPOOL
•
Permit No.
Fee '$
DATE c'7"\C- / D O /
1
APPLICANT NAME: O,j�$ �� S
APPLICANT ADDRESS: 02/-6'
M 71A i'a � N ///�s .
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONST UCTIO OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
• OWNER OF PROPERTY: /ice;/77 as gra- �s
OWNER MAILING ADDRESS: cC‘ VS S K`
OWNER PROPERTY ADDRESS: /-5-D 75%,d/e---5-7/
uey7
TELEPHONE NUMBER OF CONTACT PERSON: (2(5) 302--
TAX MAP NO. : Section / Block 6=2- Lot
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
•
Signature of Applicant
RECEIVED B�
Town Clerk's Office
DATE: 3 1-4
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES DEPT OFF rli�Lii_} '�
h NV 1,11.
RJVERHEA,O NY 11501.
PERMIT FOR APPROVAL OF CONSTRUCTION PM A
SINGLE FAMU Y RANGE ONLY
DATE /0/2-5/
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