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Home My WebLink AboutNorth Fork Surgi Center :r �oggfFOLKcD'- ELIZABETH A. NEVILLE,MMC �y� �fy Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p Fax(631)765-6145 MARRIAGE OFFICER 7'� a��' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE OWN O SOUT OND CLERK D D TO: Southold Town Building Department FEB - 8 2018 FROM: Sabrina Born, Southold Town Clerk's Office 13tT1aDY j-' TOWN OF SOUTHOLD DATED: February 6, 2018 RE: Cesspool Construction Application Transmitted herewith is a copy of application No. C4562 for a Cesspool/Septic Tank Construction Permit submitted by: North Fork Surgi Center 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 r Signature , Dated 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 m, 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: February 6, 2018 RE: Cesspool Construction Application Transmitted herewith is a copy of application No. C4562 for a Cesspool/Septic Tank Construction Permit submitted by: North Fork Sur i Center 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 appy al, re uired from the Suffolk CountyHealth DeDa tinent Signature Dated Town Hall, 53095 Main Road ELIZABETH A.NEVILLE d` P.O. Box 1179 TOWN CLERK Southold, New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631) 765-6145 MARRIAGE OFFICER " Telephone (631) 765-1800 RECORDS MANAGEMENT OFFICER " �� southoldtown.northfork.net FREEDOM OF INFORMATION OFFICER 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 @ $2 Application No ,. Permit No. � " Applicant Name mIT �.. aL Applicant Mailing Address .._ Sc)lic S" or Cesspool r Alteration ... ._ C."G1"' ti 11 f".P1,°C1)ose onstruc lon o � C Location of Proposed Construction/Alteration: Owner of Property:. _ a Owner Mailing Address: Owner Property Address: " - . . Name and phone number of contact per qI Tax Map No: Section Block _ Lot Cross Street 41 NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURV JEALTH DEPARTMENT AP I O Al, Sign tulofApplicant Date Received by: _..- XXOx M3N'O'IOH.LIIOS 496Z-99L(M) HnNa"rivasSIOfl 90L AN'OIOHinos k MV`1c1 FIDS.I�AIHI�1i.L2I�'12M H1'IVaH N33NION3 XVNOI S3.� °f W 4a}ua:)�64nS ploy}nos i F �.µ Ev ..r ;i �I I mw OF i {. t; �z.d n w tarp l r, bo ,01 P z?IV w k � � Y Opl;�iry��' r dY '.Fj Po O �•� L. W. I Ell ,. ail IN ua LA uj qw , le HAA VL'YY �d� 1 w4 �I f W �.o1 )� � a YI F_a L q