HomeMy WebLinkAboutHerzog, Joseph F 1
ELIZABETH A. NEVILLE,MMC Town Hall,53095 Main Road
TOWN CLERK 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.;ov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN
yO Ny CLERK
TOW OF SO V THOLD
TO: Southold Town Building Department
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: February 27, 2017
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4466 for a Cesspool/Septic Tank Construction
Permit submitted by:
John Chiarelli for Joseph Herzos
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. NEVILLE `� G�� Town Hall, 53096 Main Roa,
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER ��fo ®� Telephone (631)765-1800
FREEDOM OF INFORMATION OFFICER southoldtown,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. a
Permit No. ( " J --0090
Applicant Narne
C � iC' et
Applicant.Mailing Address ('
Septic Tank. or Cesspool /
Brief Description of Proposed Construction or Alteration � , �
Location of Proposed Cons truction/Alteration:
Owner of Property: } "
Owner Mailing Address:_
Fv�
Owner Property Address:_
Name and phone number of contact person j 0 k'j4 . t 1( r
Tax Map No: 12 i) Section Block_ Lot
Cross Street i 1 1 A die@
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION RE QUIRES SURVEYT, A
H ISE AI�.T +NT APPROVAL
'r 7
Signaturplicant I7 to
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