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ELIZABETH A.NEVILLE ;_S ? Town Hall,53095 Main Road
TOWN CLERK o - P.O.Box 1179
y Z Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER `� �*'���, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER "nthsig • S,i Fax
(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. 3079 R Residential X Non-Residential
Fee $ 10.00 Septic x Cesspool
PERMIT ISSUED TO:
Name : MORRIS CESSPOOL
Address 1: 2760 YENNECOTT DRIVE
City St Zip SOUTHOLD NY 11971
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 INSPECTINO REQUIRED.
Name Of Owner NEUMAN, HELEN
Mailing Address 1 27 MIDDLETON AVENUE -
City St Zip GREENPORT NY 11944
Property Address 1 27 MIDDLETON AVENUE
City St Zip GREENPORT, NY 11944
Tax Map No. section 40.00 block 5 lot 11.000
Cross Street -
Building Permit Number Cross Reference:
Issue Date: 9/08/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
'r
y '�` ,ill OFFOl ; 3677 .
ELIZABETH A.NEVILLE 'I O10 Town Hall, 53095 Main Road
TOWN CLERK p P.O.Box 1179
tiZ , Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS ; t
/� Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER .z=y ea.."0
Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER =?e'� 4,�� ,, '• southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD r----�— •-
TO: Southold Town Building Department ; E° _ 3 ;
FROM: Linda J. Cooper, Southold Town Clerk's Office i
DATED: September 3, 2003
Transmitted herewith is a copy of application No. 3210 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Morris Cesspool/Helen Neuman
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 loc tion 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. .
2ire,.9/‘,4.,
Signature
.40 .•-,--4-,_., 3, ,-rte 5
Dated
0""FOL,
ELIZABETH A.NEVILLE 'II° ` Gy%- Town Hall, 53095 Main Road
TOWN CLERK p P.O.Box 1179
ti a Southold New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ,�� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER -may* ®��i�� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER =®°`I* southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @ $25 Application No. 3 oZn
/�/�
�c Permit No.
Applicant Name /4 d f2& ()5 4o r
I
Applicant Mailing Address 2 v CC a rr
Septic Tank or Cesspool r f
Brief Description of Proposed Co :{ ction or Alteration
Location of Proposed Construction/Alte prix: ation: 7/7(Owner of Pro e �/," /1 / im ✓
�,t/ 7� /_7
Owner Mailing Address: 2 ? , ;W % o
d e®
Owner Property Address:
Name and phone number of contact person 7‘.5--- 72
Tax Map No: Section ��U Block Lot %
Cross Street
NOTE: LOCATION MAP MUST QBE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
(?-0-7/Ar ‘ ,/,(7"-,—
Signature of Applicant Date
Received by: )
I
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