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ELIZABETH A. NEVILLE,MMC Town Hall,53095 Main Road
TOWN CLERK m P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 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: January 13, 2017
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4457 for a Cesspool/Septic Tank Construction
Permit submitted by:
Paul Davey for Equity Trust
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
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ELIZABETH-A. NEVILLE e ��O G�� Town Hall, 63095 Main Roa,
TOWN CLERK � P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS by
MARRIAGE OFFICER Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER ��f� ®� Telephone (631)765-1800
FREEDOM OF INFORMATION OFF,ICER r �` southoldtown,northfork.net
OI<FICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 r
or Non-Residential @$25 Application No. z
Permit No.kto -/�, O
Applicant Name 11�. 1t
Applicant.Mailing Address
Septic Tank. or Cesspool
Brief Description of Proposed Construction or Alteration At�2,---)
Location of Proposed Construction/Alteration:
Owner of Property:_ C ,�, d v i ! `
Owner Mailing Address:
Owner Property Address: AJ
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Name and phone number of contact person po�U (4
Tax Map No: Section /(-I Block`_�_ Lot.
Cross Street
NOTE: LOCATION MAP MUST BE SUBAUTTED WITH APPLICATION. NEW
CONSTRUCTION +QUIRES SURVEY WITHREALTH D +P A R T E NT APPROVAL
y w t
Signatdr6 of Applicant Date
Received by:
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