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ELIZABETH A.NEVILLE, MMC �g11FFOL�cO 0 Gy Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS %0. Fax(631)765-6145
MARRIAGE OFFICER ,y �`. Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER �Ol �`1 www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
D ���Od�
TO: Southold Town Building Department D
JUL 2 2018
FROM: Sabrina Born, Southold Town Clerk's Office
DATED: June 28, 2018 BUILDING DEPT.
TOWN OF SOUTHOLD
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4622 for a Cesspool/Septic Tank Construction
Permit submitted by:
Krzysztof Zebrowski for Jill Tanner.
Please review the application and location map and advise if this office may issue the permit.
'lease 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
07 mg
Dated
ELIZABE'1CFI A.NEVILLE �`�® .� Town Hall,53095 Main Road
TOWN CLERK � � P.O. Box 1179
coo Southold,New York 11971
REGISTRAR OF VITAL STATISTICS W �►S
MARRIAGE OFFICER ap �` Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER4 Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER ®Q'! 3outholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 V or Non-Residential @$25 Application No. a�
Permit No.
Applicant NamerV"�il� ��
Applicant Mailing Address aft (�31 EP's lbm
Septic Tank "\/ or Cesspool
Brief Description of Proposed Construction or Alteration 9 CW- 1C 09 rAl i,tDN S lC i MC
AND of t�_H_Cd'l l iYG-mot ����� wl Th /61 �� caa 2 ' 41 N A OG Ul✓ WHO v#tet
Location of Proposed Construction/Alteration:
Owner of Property: u T A P PM
Owner Mailing Address: ?)7 UT OU MA R '
Owner Property Address: V521_0 DC-71,14AIZ DR
LAV RR 11 q�I
Name and phone number of contact person _
Tax Map No: Section— '7 Block Lot aJr
Cross Street t-P4-1 ��
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICA'T'ION. NEW
CONSTRUCTION REQUIRES SURVE WITHHEAL )81 DEPARTMENT APPROVAL
Signjare of Applicant Date
Received by: _
SARA&E 2079 5Q. FT0r \
'9 X I X 0.17 • 354 GU. FT..
01*1
RAVEL GRIVEWAY • 1040 5Q. FT. 044 10 eg!)
0 ' X 0.17 • 177 GU. FT.. N \ \4\A" 34k
531 GU. FT.. � S
531/42.2 12.6 V.F.
'3"
DRY W ELL5 84 X 7' DEEP I 1
OR EQUAL
=LL GONNEGT TO HOU5E
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11-5 84 X 6' DEEP
COLLA,' 3' MIN. ABOVE
EP
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