HomeMy WebLinkAboutByrne, Thomas ���� ` �
�I,IZ1���Tt$A. I�1Ei��I,LE,1VIlVIC �� � Towi�Hall,53095 Main Road
���� �j,��� � P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � Fax(631)765-6145
MARRIAGE OFFICER �' Telepl�one(631)765-]800
RECORDS MANAG�MENT OTFICER �� � www,southoldtownny.gov
FREEDOM OT INFORMATION OI'FICER
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TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: August 24, 2016
Transmitted herewith is a copy of application No. 4417 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Thomas Bvrne
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. Thank you
* * �: � * * � � � * * �
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, buildin�s, property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
Signature
I�ated
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ELIZABETH A. NEVILLE �°`� �G� Town Hall, 53095 Main Road
TOWN CLERK q�' � P.O. Box 1179
� � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � �
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER ��f�� ���� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
�l'A'i�ili' �T'' d�1�' S�tlY 1V �iT e.�:�i�
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10� or Non-Residential @ $25 Application No. "�'���
Permit No.
Applicant Name i �� ��� �
Applicant Mailing Address � !s!�
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Septic Tank or Cesspool ,
Brie Description of Proposed Co structi n or Alteration ��r,
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Location of Proposed Const ction/Alteration:
Owner of Property: I �� �'
Owner Mailing Address: l .�
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Owner Property Address: �� �' ►
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Name and phone number of contact person �� � �
Tax Map No:���� Section Blocic � Lot �
Cross �treet � �
1�0'I'�: I.00�T'IOl� I�AP IVI�J�T' �� SIJ�Il�I'I'rI'�D 'WITI� APPI,ICA'I'IONe I�E�
COl�tST'RIJC'TIOI�T i�QITIII�S SIJIgV��' I�'�I I�EAI.'TI� DEPr�R'I'1VI�l�T' APPItOVA�.
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�i nature of Applicant Date
Received by: /
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8'X12' SHED LP 8 EP
DRIVEWAY
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