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ELIZABETH A.NEVILLE 0 OG'yd Town Hall,53095 Main Road
TOWN CLERK o P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER `� 1i �� �, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = �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. 3097 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : RUDOLPH KOEHLER
Address 1: 4265 NORTH BAYVIEW ROAD
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 YOUNG, JR ALFRED
Mailing Address 1 PO BOX 745
City St Zip SOUTHOLD NY 11971
Property Address 1 4265 NORTH BAYVIEW ROAD '
City-St zip SOUTHOLD NY 11971
Tax Map No. section 79.00 block 3 lot 13.000
Cross Street
Building Permit Number Cross Reference:
Issue Date: 10/20/03 Elizabeth A. Neville
Southold Town Clerk
(TQWN SEAL)
3(377
ELIZABETH A.NEVILLE /0 *d\ Town Hall, 53095 Main Road
TOWN CLERK % p P.O. Box 1179
Ze
REGISTRAR OF VITAL STATISTICS � yj, Southold,New York 11971
MARRIAGE OFFICER : �` 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =y�f� a0�'1�� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER = '( * *"•,60 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD _
TO: Southold Town Building Department i • SEL ? 3 ?()n;
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: September 23, 2003 -
Transmitted herewith is a copy of application No. 3232 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Rudolph Koehler
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.
Signature
A
Dated
A.- )II° ,,,,,,,,,,,
ELIZABETH A.NEVILLE 1",#s •y : Town Hall, 53095 Main Road
TOWN CLERK _ ' p P.O.Box 1179
REGISTRAR OF VITAL STATISTICS $ Southold, New York 11971
MARRIAGE OFFICER
Fax V$ Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ' * 0.eie Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER =?4'1 l +196.1
19 southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
✓ _ -5)32"
Residential @ $10 or Non Residential @$25 Application No.
// Permit No.
Applicant Name dee,/,/,vi %:;, -G/4---2
Applicant Mailing Address 5'� ,_ ..- /r/ /- ' � /
��. . 1, � ': ///77 c/
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration zA'. ,// o ig-e ���
/ c:7,4/7f. &-errs/zrvy ..., 70-.,117
Location of Proposed Construction/Alteration:
Owner of Property: /9� GiVJ()
•
ulsa-
Owner Mailing Address: _IL c Y
P\/ 11911
Owner Property Address:
Name and phone number of contact person �i/t / 7`', .0 ,S/G 723 /5_9
Tax Map No: Section 1? Block 0 3 Lot 13
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
.4.,L‹. _‘.... -.,,,,,, '2_3-, __
Signature of Applicant Date
Received by: '
t "
ir, ,...........—..—.....,..--..—........... ...........
` STREET ADDRESS: 4265 NORTH BA YIS4EW ROAD -a
��fi �1p4 - -SURVEY OF PROPERTY
•N - AT BAYVIEW
^:, • TOWN OF SOUTHOLD
,I SUFFOLK COUNTY, N. Y.
' ` trio 1000-79-03-13
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.3�3°b�`gN F`. �4 CERTIFY D TO:
�. °y +y� ^ Q RUDOLPH KOEHLER, JR.
S 9 p -. Q, RITA MARIE KOEHLE'R
N/O/F S [..,„..0 .
s QAC c� CHICAGO TITLE INSURANCE COMPANY
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P CONIC SU ` , g•' -„1,1 011
, ANY ALTERATION OR ADDI77ON TO,THIS SURVEY IS A VIOLATION (631) 765-50 : _ . 1 ) 765-1797
OF SECTION 72O9OF THE NEW YORK STATE EDUCATION LAW.
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS ■=MONUMENT P.O. BOX 909
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF 1230 TRAVELER STREET
• SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR AREA-22,004 S F. • PIPE02-c�� ►�
WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971