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ELIZABETH A. NEVILLE ; � * Town Hall, 53095 Main Road
TOWN CLERK 1 o - P.O. Box 1179
ti Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ` P
MARRIAGE OFFICER ?i �! �,� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER � �Ql ali �ao'i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER 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. 3039 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : DONALD FELLER
Address 1: PO BOX 1092
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
SEPERATE SYSTEM TO EXISTING DWELLING.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED. R10-02-0193
Name Of Owner SIRACUSANO, LOUIS
Mailing Address 1 895 NORTH PARISH DRIVE
City St Zip SOUTHOLD NY 11971
Property Address 1 895 NORTH PARISH DRIVE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 71.00 block 1 lot 9.000
Cross Street DAYTON ROAD
Building Permit Number Cross Reference:
Issue Date: 6/11/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ill OFF0/40,1% °'3e(
ELIZABETH A.NEVILLE ��i• 4®4�; Town Hall, 53095 Main Road
TOWN CLERK sp P.O. Box 1179
cox Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS OPrt MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER L �0 aOft Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER = '` �." southoldtown.northfork.net
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1OFFICE OF THE TOWN CLERK
MAY 14 2003 TOWN OF SOUTHOLD
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a j ,
T• Tom & A% uilding Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED:
Transmitted herewith is a copy of application No. 3163 for a Cesspool/Septic Tank Construction
Permit submitted by:
Louis Siracusano
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:
"Signature
Dated
._
OFFICE OF PHN,TOWN CLERK •'''�c�� Mir
TOWN OF SOtJTHOLD Os .., 4'414:: Application No. 3 G�j
ELIZABETH A NEVI)J.F,TOWN CLERK �� O
BOX 1179 • � . ; Construction ,...,---
P.O.
SOUTHOLD,NEW YORK 11971 ; v rn
Fri) / Alteration
Telephone %O,jj� 1 •1"/ $10.00 - Residential
(516) 765-1801 _ �1 �,�. $25.00 - Non-Residential
-- .,.,i,,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee .$ I
DATE � �I tii.
APPLICANT NAME: tj.AI.An `. ,__
'APPLICANT ADDRESS: 1 Pct 0 1110 Po 60Y / t i Z
M. P -rnWC
SEPTIC X CESSPOOL'-
DESCRIPTION
�O F PROPOSED CONSTRUCTION OR ALTERATION
I O.D 1 -1 ,7 o t ), Ow t—u. 6 — 3 E.-e19 le 6 T
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
• OWNER OF PROPERTY: Lo U is J112 -(U5Pcf\f Q
OWNER MAILING ADDRESS: 8,9,5 N Pits - . D (2,
0 -1 "OvO
OWNER PROPERTY ADDRESS: .5P.i 1 6
TELEPHONE NUMBER OF CONTACT PERSON: 29
TAX MAP NO. : Section .71 Block 1 Lot 1
CROSS STREET: DP`\1) TO (lip
BUILDING PERMIT NUMBER CROSS REFERENCE:
Ot..„420 . .1_.___
Signature of Applicant
RECEIVED B Y: _ �,�',�,c'`i I( ,
own Clerk's Office
DATE: 5/�� Q 3
• .I SURVEY OF PROPERTY N
.SITUATE: BAr'VIE1N s - PECEI1VEU
TOWN OF SOUTHOLP LPPOL�I COUP�'ry W - E
1003lPAn 10.SUFFOLK COUNTY', NY io R-1
SURVEYED II-12-RS Q' "'- ,I;I ,- S
updaREVlte survey SED 20 8-02,04-30-02 , , 4YgIEWA;Ett MG
rev 06-24-02, test hole added 08-12-02 .
revised OR-18-02, 11-26-02
SEPTIC LOCATED OI-O1-03,amended 04-01-03 ii
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SUFFOLK COUNTY TAX in S i0
1000 - 11 - I - R / 70
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CERTIFIED TO. Co S4►E a' id
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LOUIS 51RAGU5ANO Ng;Tote,^9 \ \-i,`Q/on L�/ J m Ai
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SUFFOLK COUNTY DEPT HEALTH SERVICES '\ - er .2-98,-,
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Top" 11/n9 EXPIRES THREE YEARS FROM 0 Y.OF APPROVAL
NOTES W Qter No,,,,,
■ )' 150
MONUMENT FOUND -
0 PIPE FOUND �: -_
HEDGE tAQC',OC. Ey1 10:
REFERENCE DEED L 11118 P 30R73�
° :q° tf G-,/', pis,
AREA = 23,031 5F OR 053 ACRES J ( ,�,,X t/ �t;'
PROPERTY ZONE R-40 :a` ` °6. °°°„ �\ 4 rea r, t
FLOOD ZONE X AT HOUSE SITE °�:°@ ;; ;;; ;;';';' 0,..,
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SEPTIC LOCATIONS A5 PER OWNER • :,: °r' ` .::�""R; r0 LAND 9_,, #,�
«" JOHN C.EHLERS LAND SUR' 'OR
GRAPHIC SCALE 1"= 30 ,y6EAST MAIN STREET NYS LIC NO 50202
b ' RIVERHEAD,N.Y 11901
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