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ELIZABETH A.NEVILLE 1�� ® ®�'��; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS
MARRIAGE OFFICER :‘15)�i 410 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER -_�®1 4°r���®0. Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2896 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : CATHERINE MESIANO INC
Address 1 : 12 MILL POND LANE
City St Zip EAST MORICHES NY 11940
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-02-0049
Name Of Owner NICKICH, MICHAEL
Mailing Address 1 155 FLORAL AVENUE
City St Zip BETHPAGE NY 11714
Property Address 1 4297 WELLS ROAD
City St Zip PECONIC NY 11958
Tax Map No. section 86.00 block 1 lot 9.005
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 9/24/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE ����� * .` Town Hall, 53095 Main Road
TOWN CLERK Y 2 ; P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS ; PPV Southold� ' New York 11971
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MARRIAGE OFFICER `` Fax Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �__ ®� 4133 ��®,i� Telephone (631) 765-1800
FREEDOM OF INFORMATLON OFFICER �����,�,���� southoldtown.northfork.net
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t�' i 1', , OFFICE OF THE TOWN CLERK
,l ' k S�P 20 02—
i-- TOWN OF SOUTHOLD
t TOS, ;i ‘s -'Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: September 11, 2002
Transmitted herewith is a copy of application No. 3007 for a Cesspool/Septic Tank Construction
Permit submitted by:
Catherine Mesiano, Inc.
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: ,....‘�.�-0...A
7/7"..e:4 ,ai i y ,
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Signature
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OFFICE OF THE TOWN CLERK •� ,,, /•••,,,,
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TOWN OF SOUTHOLD � Qy:, Application No. 7
FTJ7ABETH A.NEVILLE,TOWN CLERK i
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971
v • rn ;
• c 3 � Alteration
Telephone � $10.00 -Residential
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(631) 765-1800 =- 1 �,•0'� • $25.00 -Non-Residential
TOWN OF SOUTHOLD •
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
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• APPLICANT NAME:
CATHERINE MESIANO,INC.
APPLICANT ADDRESS: ! { 12 MILL POND LANE
E. MORICHES, NY 11940-1222
SEPTIC I CESSPOOL 31
DESCRIPTION OF PROPOSED CONSTRUCTION—OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATI�/O�N': r
• OWNER OF PROPERTY: f' U l Ge. Q �' ` bz.„,.µ. I l UC�C.L
OWNER MAILING ADDRESS: 1 5 5 .
41-, -41A-- f1/2 117 '5'
OWNER PROPERTY ADDRESS: -) 1 q - Q/
TELEPHONE NUMBER OF CONTACT PERSON: (D 3/- Y71— ?”/
TAX MAP NO. : Section S e Block Lot 9' 5
CROSS STREET: 17)(10.,t ILS
•
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
_ 4RECEIVED BY: L
Town Clerk's Office
DATE: (13\\\ PI'
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT FOR APPROVAL OF CONSTRUCTION FORA �0 43• 1�''�.
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