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ELIZABETH A.NEVILLE
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Town Hall, 53095 Main Road
TOWN CLERK % O - P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax(631) 765-6145
MARRIAGE OFFICER ,L
RECORDS MANAGEMENT OFFICER `� "'/Ql �aoi��' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER r��� 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. 2859 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 GOLDMAN, ROBERT T
Mailing Address 1 211 CENTRAL PARK WEST 9E
City St Zip NEW YORK NY 10024
Property Address 1 930 JACKSON STREET
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 117.00 block 10 lot 6.000
Cross Street NEW SUFFOLK AVENUE
Building Permit Number Cross Reference:
Issue Date: 7/23/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ,f1.1yd; Town Hall, 53095 Main Road
TOWN CLERK y - P.O. Box 1179
d,, t Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ® Fax(631) 765-6145
MARRIAGE OFFICER 4i
RECORDS MANAGEMENT OFFICER =_7®� -too Telephone (631) 765-1800
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: June 17, 2002
Transmitted herewith is a copy of application No. 2937 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Peconic Cesspool for Robert Goldman
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.
.e;
Signature
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Dated
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OFFICE OFTHE TOWN CLERK '�� CAVVULire
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TOWN OF60Vf1I0LD �%'6‘ b
®�= Application NO 57
EL1ZA13HTH A.NHVli1.H,TOWN CLERK
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P.O.BOX 1179 .`,l ' Construction ls‘
SOUTHOLD,NEW YORK 11971 •
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P rn Alteration
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Telephone ,f 40v1, $10.00 - Residential
(631) 765-1800 „ 1ses - $25.00 -Non-Residential
.ai/,, -
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
RECEIVED
for
CONSTRUCTION or ALTERATION PERMIT ” JUN 17 2002
SEPTIC TANK or 'CESSPOO L
Southold Town Cleric
Permit No.
Fee .$
DATE (elf
APPLICANT NAME: PECONIC CESSPOOL
APPLICANT ADDRESS: P. 0. BOX 972
MATTITUCK, NEW YORK 11952 '
SEPTIC CESSPOOL /l/
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION •
LOCATION MAP: Must be attached hereto before permit may be issued. '
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
. OWNER OF PROPERTY: AO aa-T, ' ��,/ 74-4/
t OWNER MAILING ADDRESS: ' -,I/ e -�p�� q�� �� � 1,1/ 77 ( qe-
OWNER PROPERTY ADDRESS: 95,e / 7'
s.h)4.44, , A/6-4 yert.t .
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section 117 Block `0 Lot
CROSS STREET: V+•v' c
#R-14.-441, •
BUILDING PERMIT NUMBER CROSS REFLRENCE:
•
Signature of pplicant •
RECEIVED Bier •
Tow Clerk's Office
DATE: Cr? ��"
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