HomeMy WebLinkAboutRerisi, Gail f FOLIr
ELIZABETH A. NEVILLE,MMC Town Hall,53095 Main Road
TOWN CLERIC m P.O. Box 1179
C4 at 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 20, 2017
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4461 for a Cesspool/Septic Tank Construction
Permit submitted by:
Gail Rerisi
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
0
ELIZABETH A. NEVILLE �`Z� G¢r� Town Hall,63095 Main Roa.
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �.
MARRIAGE OFFICER r ` Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER y�®� ��0� Telephone (631) 766-1800
FREEDOM OF INFORMATION OFFICER southoIdtown.northfork.net
OFFICE OF THE TOWN CLERK
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 w r i- 1�j
Applicant_Mailing Address YaO SjVu,6 1�,411,604
Septic Tank-X Cesspool X
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:-
Owner Mailing Address: 90,19,5-Na-.6 �w &4
Owner Property Address: 441, / `i"
Al n q3 VJAV aj e,
Name and phone number of contact persons
Tax Map No: Section %1,g-16 Block 4-a 1 Lot j�>
Cross Street Mr+,"1 —9,4 ,ez,J D
NOTE: LOCATION MM MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SUR ffEALTH DEPARTMENT APPROVAL
_ 'Signature of pplicant Date
Received by: — r
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