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ELI2,ABETH A.NEVILLE ��,� Gid•
Town Hall, 53095 Main Road
TOWN CLERK ® - P.O. Box 1179
ill 1
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ® �� Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER `=��®1 43 NO./ Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2721 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : CAROLE RICH
Address 1 : PO BOX 720
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner WILDER, DON
Mailing Address 1 PO BOX 720
City St Zip MNATTITCUK NY 11952
Property,Address 1 2435 LAUREL WAY
City St Zip MATTITUCK NY 11952
Tax Map No. section 121 .00 block 4 lot 16.000
Cross Street SOUND AVENUE
Building Permit Number Cross Reference:
Issue Date: 1/11/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
al
ELIZABETH A. NEVILLE ,���_� ®Gyp; Town H 1, 53095 Main Road
TOWN CLERK y - P.O.Box 1179
REGISTRAR OF VITAL STATISTICS � � �
Southold, New York 11971
MARRIAGE OFFICER ` �i �����, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER "'/Ql $ '�,� Fax
(631) 765-1800
Jig
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: January 3, 2002
Transmitted herewith is a copy of application No. 2816 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Carole Rich
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 loca ion 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.
Signature
0///3///6#2-
Dated
/ d3 6# a-
Dated
OFFICE OF THE TOWN CLERK , ,',,,,.,
Town of. Southold ,�,�'OCj�FFOLK�'OG Application No. v Q
e6
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Z ; Construction @/
P. O. Box 1179c rn ;
Southold, New York 11971 , trs Alteration�
Telephone .
�'� $10.00 - Residential
(516) 765-1801 = �1
, $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC, TANK or CESSPOOL
Permit No.
Fee $
ICf JDATE
APPLICANT NAME: / j / Qom'
APPLICANT ADDRESS: ,,2 (7/-1,S� 94,40/ 1/fr/"V NY-77-)0
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CO STRUC ION OR ALTERATION
fca 74,"/ re-4-
co /do/ ,ce2f- ea4 .
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: .i:/ J ,rI V
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: a12S Lauut..AA
TELEPHONE NUMBER OF CONTACT PERSON: �•�l7 7r / �y`�
TAX MAP NO. : Section ! f Block Lot 1 6)
CROSS STREET: ,_/;‘,1 4,1,A
BUILDING PERMIT NUMBER CROSS REFERENCE:
0 Sig r jyture of Applicant,
RECEIVED BY pA
'own Clerk's Office
DATE: 0
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