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ELIZABETH A. NEVILLE d �6, * Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �; • /% Southold, New York 11971
MARRIAGE OFFICER
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afi �, 11 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ®1 ��®��i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER — „",������
OFFICE OF THE TOWN CLERK
SOUTHOLD IVAVIVMATIEIRITICaBIDSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2677 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : EUGENE JACOBSEN
Address 1 : PO BOX 381
City St Zip EAST MORICHES NY 11940
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 #10-01-0203
Name Of Owner KERENSKY, BILL & LINDA
Mailing Address 1 835 STROHSON ROAD
City St Zip CUTCHOGUE NY 11935
Property Address 1 145 BALDWIN PLACE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 103.00 block 10 lot 2.003
Cross Street LITTLE NECK ROAD
Building Permit Number Cross Reference:
Issue Date: 10/18/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
( .07-7 17
el OFFOLAr
®ELIZABETH A. NEVILLE ,����� �� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICSI Southold, New York 11971
MARRIAGE OFFICER � ��� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER "'/® ��®�i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER 41 .
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: October 17, 2001
Transmitted herewith is a copy of application No. 2769 for a Cesspool/Septic Tank Construction
Permit submitted by:
Eugene Jacobsen
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: 4 r G�
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7x.../274:57cie
Signature
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Dated
OFFICE OF THE TOWN CLERK el'' 01./(4 f�
TOWN OF SOUTHOLD %`. Application r14�Gy:� Application No. �J
ELIZABETH A.NEVILLE,TOWN CLERK Y O l
P.O.BOX 1179 • Constructio
SOUTHOLD,NEW YORK 11971 v
• Alteration
•
Telephone ,� $10.00 - Residential
(516) 765-1801 =�01 � ' $25.00 - Non-Residential
TOWN OF SOUTHOLD
RECSIVED
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OCT 1 7 20W
APPLICATION 3 ffl Ia Notavn Clerk
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE /5 - o /
APPLICANT NAME: Ft/6511g J9J'
g�
APPLICANT ADDRESS: pa, i o,c
® Maieichs, /4)( • //f9/62
SEPTIC CESSPOOL IV-
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
iki1h/ hi, � 1 �1( % /GtJ ✓ o
of /Ablidq � - , 15A
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: 23/4/4 1,1494 k' A/5 "
OWNER MAILING ADDRESS: g3S
,6UT 06 vim,, Aly /mg-
OWNER
1 q3 -OWNER PROPERTY ADDRESS: /4/ 2"447k1 P4(('S6
Aly 1193,5-
TELEPHONE NUMBER OF CONTACT PERSON: 6,31 " 7 375S"
TAX MAP NO. : Section /o.3 Block /0 Lot 3
CROSS STREET: 1i/7(/ff f ,Ip,
BUILDING PERMIT NUMBER CROSS REFERENCE:
.40
..pure o • pplicant
1�
RECEIVED B
Town Clerk's Office
DATE:
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