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ELIZABETH A.NEVILLE 101 Town Hall, 53095 Main Road
TOWN CLERK ® P.O.Box 1179
, Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 4'
ry �1 Fax (631) 765-6145
MARRIAGE OFFICER *'",
RECORDS MANAGEMENT OFFICER �;_ ®1Mg *® /1. Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �����•,,r��� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2744 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : SCOTT & CONNIE ELLIS
Address 1 : 47100 MAIN ROAD
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
ADDITION TO EXISTING SYSTEM.AMILY DWELLING.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENTMENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner ELLIS, SCOTT & CONNIE
Mailing Address 1 47100 MAIN ROAD
City St Zip SOUTHOLD NY 11971
Property Address 1 47100 MAIN ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 69.00 block 6 lot 11 .000
Cross Street SOUTH HARBOR LANE
Building Permit Number Cross Reference:
Issue Date: 2/20/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
an4-1/--q
ELIZABETH A.NEVILLE ��t Town Hall, 53095 Main Road
' TOWN CLERK ; - P.O. Box 1179
Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS
MARRIAGE OFFICER Fax (631) 765-6145
eai �. �1
RECORDS MANAGEMENT OFFICER =__ r ��®'i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ,.901
" southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD •il
1.
TO: Southold Town Building Department FEB 5 ? t' '
FROM: Linda J. Cooper, Southold Town Clerk's Office I-
DATED: February 5, 2002
Transmitted herewith is a copy of application No. MIS for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Scott and Connie Ellis
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: Maintain required setbacks from adjacent wells,buildings,property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
_07
ff
Signature
e9.2--//0 Ve-z—
Dated
TYPICAL LEACHING POOL REU\,<)11 2-t-t—o,
FINISHED 4 4 4
GRADE t SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
1 MIN, 2' MAX
Rmrr FOROR APPROVAL OF CONSTRUCT=D f FORA
CONCRETE COVER II4' MAX. CLE FAMILY RESIDENCE ONL
CONCRETE _
DATE 1--2.3-O�-- HS F.NO.. _I°701-:-.P2-51
CHIMNEY APPROVED
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i-- 2O --I FOR MAXIMUM OF 7 'RO01!`_'1
INLET EXPIRES THREE YEARS FROM DATE OF APPROVAL
RM. 4' DUl
APPROVED
PIPE -
PRCRED
1/Er/I' i Abandonment of existing sanitary system
lei, ❑ ❑ El ❑ ® � ��� to be witnessed by Health Department.
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NIGH SEASONAL GROUNDWATER I
BACK FILL MATERIAL TO BE CLEAN SAND AND GRAVEL
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OFFICE OF THE TOWN CLERIC '•,,,•••••••••,,
COoc
TOWN OF SOUTHOLD
�`� �c :_
El.17ABETH A.NEVILLE,TOWN CLERK �G Application N o �
P.O.BOX 1179 � •
Construction
SOUTHOLD,NEW YORK 11971 ; 'Z
v
U-3Alteration �^
Telephone :0S 00r��- - $10.00 -Residential 1
(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 , 2/3-1c9
APPLICANT NAME: Gee') -(--- 9- n in"c e elLS
APPLICANT ADDRESS: g----0 100 f \&ir,
�(:
(40.(At Y 071
SEPTIC /CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
ii?()couk. \rAe.0(\
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: -
OWNER OF PROPERTY: S7c2 — c- C2,,u,e.... cI Ls
OWNER MAILING ADDRESS: `
71 DCS I(I�/��,d1 A.
€ 19410V, Li ill 7 I
OWNER PROPERTY ADDRESS: -5a.n.Q,
TELEPHONE NUMBER OF CONTACT PERSON: `7 - (0,
TAX MAP NO. : Section ii6 / Block Lot 1
•
CROSS STREET: 50LA\ 0,(U-kCe•CA-
.
BUILDING PERMIT NUMBER CROSS REFERENCE:
47,(.--g OA
,(! Signature of Applicant
RECEIVED BY: c -
T wn Clerk's ice
DATE: c0/6es......„