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ELIZABETH A. NEVILLE, MMC �+" Town Hall,53095 Main Road
TOWN CLERK " P.O.Box 1179
Southold,New York 11971
cm
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: May 31, 2018
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4617 for a Cesspool/Septic Tank Construction
Permit submitted by:
Peconic Cesspool for Shirley Anderson
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:
Signature
Dated
FQZ
ELI E,TH A. NEVrLLETown Hall, 53096 Main Roa-
TOWN CLERK � P.O. Box 1179
REGIST OF VITAL STATISTICS �
Southold New York 11971
MARRIAGE OFFICER ` Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER ° Telephone (631)765-1800
REEDOiv1 OF INFORM
ATION OFFICER `*.. 1 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANI{
Residential $l0 or Non-Residential@$25-$25 A `
@ Application No.
irait No. - -. ....
Applicant Nang �"v ,
.
ApplicantAddress
Mailing
Af
Septic Tank. or Cesspool
Brief Description of Proposed on.d iction or After-at`on
Location of Proposed Constra r-bon/ t ration:
Owner of Property.
Owner Mailing Address:
Owner Property Address:_
Name and phone number of contact person I d
Tax Map No: Section �� Block Lot
d�
Cross Street
NOTE: LOCATION MAP MUST*BE SUBMITTED I7I-1 APPLICATION. NEVA
CONSTRUCTION REQUIItES SUM' ," ITLI 11EA1 DE A 1 1�" � �APPIt 11
Si ,atrue of ca It Date
Receivedby: ....... _..� ._...._
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