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ELIZABETH A.NEVILLE ���� y� Town Hall, 53095 Main Road
TOWN CLERK o - , P.O. Box 1179
c* Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS P
MARRIAGE OFFICER
:‘644_ �� �, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ; Ql #0.11.
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. 3040 R Residential x Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : PECONIC CESSPOOL
Address 1: PO BOX 972
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 FLORES, ROBERT
Mailing Address 1 670 THERESA DRIVE
City St Zip MATTITUCK NY 11952
Property Address 1 670 THERESA DRIVE
City St Zip MATTITUCK NY 11952
Tax Map No. section 115.00 block 13 lot 19.000
Cross Street NEW SUFFOLK AVENUE
Building Permit Number Cross Reference:
Issue Date: 6/11/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE i�A`Z G*...t Town Hall, 53095 Main Road
TOWN CLERK % p % P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER : G *. 0 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ‘_4,,
,,f0 �.'0-i�� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER - 1 jig : southoldtown.northfork.net
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4 :-;- '1 ; OFFICE OF THE TOWN CLERK
' TOWN OF SOUTHOLD
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• Liotos,,N -- Southold—Awn Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: May 15, 2003
Transmitted herewith is a copy of application No. 3164 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Robert Flores
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.
* * * * * * * * * * * *
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. .
, .7,74..e,4
Signature
DS/7/A3
- Dated
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OFFICE OF THE TOWN CLERK " •
AFF OLK
TOWN OF SOUTHOLD ���5 QG - Application N /‘
ELIZABETH A.NEVI LE,TOWN CLERK
P.O.BOX 1179 S���* Construction
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SOUTHOLD,NEW YORK 11971 v •
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Alteration (�
°i . Aro/
/ $10.00 ResidentialTelephone jo' , �'s
(G3t) 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 A0-1 /Y/63
• APPLICANT NAME: PECONIC CESSPOOL ((
APPLICANT ADDRESS: P. O. BOX 972
MATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED- CONSTRUCTION OR ALTERATION
L
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION• OF PROPOSED CONSTRUCTION OR ALTERATION:
. OWNER OF PROPERTY: .
OWNER MAILING ADDRESS: (D 7® °
' b%‘4r4 /tL.Cp /?S-L
OWNER PROPERTY ADDRESS: r-� S'�y, car-
TELEPHONE
arTELEPHONE NUMBER OF CONTACT PERSON: 0794F-9 'S7
TAX MAP NO. : Section PT. Block /3 Lot /9
MIMS STREET: Mr 1/
BUILDING PERMIT NUMBER CROSS REFERENCE:
TE,
Signature of Appl' ant
RECEIVED
RECEIVED BY: j
Town lerk's Office
DATE: MAY 1 5 2003
a
Southold Town Clerk
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`:i SCALE: 1n : 40• I DATE:JULY 1