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ELIZABETH A. NEVILLE y� Town Hall, 53095 Main Road
TOWN CLERK co P.O. Box 1179
REGISTRAR,OF VITAL STATISTICStJ Southold, New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
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RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential $10 or Non-Residential $25 Application No.
@ @ Pp
Permit No.
Owner Name W aC 6W `povua_ LL-C.,
Owner Mailing Address to o q RaGf�awa� '�'Wornye
VOA sem, _(Y [C57'31
Owner Property Address 4"3S_ yiacGW Pov & "Ute
(;'OU�KOCGL CrfY L (9`Z
Owner Telephone No. C %0 -32-15 '6 3 '_y
Tax Map No: Section 1'000 _7$• Block - Lot — 4
Cross Street c,
Please check each that applies: New Construction
Alteration to Existin stem
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
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Signature of pp c t Date
Received by:
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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.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SCUTHCLD VASTEVATER a SPC6AL PERM T
OCNSTRLL71 CN CR ALTERATI CN PERM T
SEPTI C TANK or CESSPOCI.
Per ni t W. 4.398 R Rbsi dent i al X %n-Resi dent i al
Fee $ 10. 00 Sept i c X Cesspool
PERM,T I SSIJED TQ
Name : M NARI N RESTCRATI CN, I NC
Address 1: 1089 ROC AVIAY AVENLE
` a t y St Zip VALLEY STREAM NY 11581
Descr i pt on of Pr oposed Const r uct i on or AI t er at i on
SAN TARP SYSTEM FCR SI NGLE FAM LY DJ'ELLI NG
APPROJED AS SLBM TTED AND AS APPROJED BY THE SLEFCLK CCI-NTY DEPARTNEM'
CF HEALTH SERA CES. FI NAL APPROVAL RECTJI RED FRCM THE SLI=FCLK CCUVTY
FEALTH DEPARTMENT. REF #R10-16-0056
Name Cf Owner VVI LLCUV PCND LAM LLC
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W I i ng Addr ess 1. 1089 ROCKAVAY AVENIE
-
a t y St Zip VALLEY STREAM------ W 11581
Property Address 1 435 VVLLOJVPa0-LM
A
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a t y St Zi p SCLJ FICLD NY 11971
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Tax Mip W. sect i on 78. 00 block 1 1 of 45. 000
Cross St r eet SLEEPY HCLLON LAM
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Bui I di ng Per nit Nifter Cr oss Ref er ence:
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Issue Date: 7/ 12/ 16 D i zabet h A Nevi I I e
-------- Sout hold Town CI erk
1
ELIZABETH A.NEVILLE,MMC may. y Town Hall,53095 Main Road
TOWN CLERK ® P.O.Box 1179
H 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
July 13, 2016
M. Marin Restoration, Inc.
1089 Rockaway Avenue
Valley Stream,NY 11581
RE: 1000-78.-1-45
Dear Sir/Madam:
Enclosed herewith is the Construction, Alteration or Modification Permit for a Septic
Tank/Cesspool System for which you applied.
AFTER the system is installed but prior to being used, an OPERATION PERMIT IS
REQUIRED. The operation Permit is issued by the Southold Town Clerk's Office. The fee is
Ten Dollars ($10.00) for a residential system and twenty-five dollars ($25.00) for a non-
residential system. Your check should be made payable to the "Southold Town Clerk". An
application form is enclosed. Please complete the requested information and return the
application, proper fee, and LOCATION MAP (map must indicate the location of the
cesspool(s)/septic tank(s), giving approximate distances in feet from any buildings to the pools
and distances between the pools.
Should you have any questions concerning this matter, please do not hesitate to contact this
office.
Very truly yours,
Carol Hydell
Account Clerk
Enclosures