HomeMy WebLinkAboutRaia, Francis V6,4f F 01
ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road
TOWN CLERK m P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS %9 Fax(631)765-6145
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: October 14, 2016
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4434 for a Cesspool/Septic Tank Construction
Permit submitted by:
Francis & Katherine Raia
Please review the application and location map and advise 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: Final approval required from the Suffolk County Health Department
Signature
Dated
ELIZABETH A. N 4 VILLG ��.� G¢r Town Hall, 53096 Main Roa
TOWN CLERK P.O. Box 1179
Southold New York 11971
REGISTRAR OF VITAL STATISTICS �. 1Z
MARRIAGE OFFICER Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER ��Ql d� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF TII + TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Restdentlal @$10 /or Noll-Residenttal @$25 Application No.��
Permit No.
Applicant Narne_ {
Applicant.Mailing Address_A t
PAP O
Septic Tank or Cesspool �-
Brief Description of Proposed Construction or Alteration
Location of Proposed Cons truction/Alteration:
Owner of Property: { ,�
Owner Mailing Address: - AkoWYrAd
ffy
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section_ Block Lot &p _
Cross Street f Iff,
NO'T'E: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVE H 'ALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received by:
(1)UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW.(2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE
INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY 15 PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTITUTION
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