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ELIZABETH A.NEVILLE,NIIVIC �y.� l/y Town Hall,53095 Main Road •
TOWN CLERK =- � P.O.Box 1179
y � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � � � Fa7c(631)765-6145
MARRIAGE OFFICER � - _ !
RECORDS MANAGEMENT OFFTCER ��,�:�_ �,`�� Telephone(631)765-1800
www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOW1�1 CLERK �(����
TOWN OF SOUTHOLD � � 15 D
TO: Southold Town Building Department
,lUl 21 ZQ16
FROM: Carol Hydell, Southold Town Clerk's Office B�D�GD��
.�OW�OF SOUTSOLD
DATED: July 20, 2016
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4407 for a Cesspool/Septic Tank Construction
Permit submitted by:
Suffolk Env. Cons. Inc. for David Levin -
Please review the application and location map and advise if this office may issue the permit.
Please complete the form below and return it to me. Thank you.
� � * � � � � * � * � *
I have reviewed the application and location map of the project cited above and make the following
recommendations: � . . '
APPROVE �
DISAPPROVE
Comments: Final approval required from the Suffolk Countv Health Department
!
l
Si ature
Dated
c, � •
o���uFFO(,�-C'
ELIZABETH A.NEVILLE �`� ���. Town Hall, 53095 Main Road
TOWN CLERK p � P.O. Box 1179
y 2 Southold,New York 11971
ftEGISTRAR OF VITAL STATISTICS � � � Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER ��f�l ���� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER � southoldtown.northfork.net
OFFICE OF TFIE TOWN CLE1�,K
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential $10 � or Non-Residential @ $25 Application No. ��7
@
Permit No.
Applicant Name ?w wt �. /tyvMW�dJY•� 'S`'��� �'w�• �S. �`lC.
Applicant Mailing Address�d� i�o d�
,(�.��c�a��ru�N. /�y 1 J �i'3�—
Septic Tank��or Cesspool ✓
Brief Description of Proposed Construction or Alteration C�d1�.+�r a l 000 'a�l�tM-
f'��. K � ' �� `�/L � / �0 ` -
Location of Proposed Construction/Alteration:
Owner of Pro e i��� �L!/LtE?S4 ti !-+�V��
p rtY� �
Owner Mailing Address: � E. /9� �T
�t/�.-�►+ y vw�c�� r o a o,3
Owner Property Address: 2� $�� IM,+N�'/� �A�
� Z�VL-1�� � .N`�
Name and phone number of contact person
Tax Map No: Section /� Block 2, Lot /�
Cross Street y2� ��� N+GAri w fZ d�►
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. IeT�W
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL '
�r� 0�. �1 1 `1 1 �o
Signature of Applicant Date
Received by:
� - SURVEY OF PROPERTY
' • IN ORIENT
TOWN OF SOUTHOLD
ISLAND '�-�` - SUFFOLK COUNTY, N.Y.
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