HomeMy WebLinkAboutBellesheim ELIZABETH A. NEVILLE, MMC Town Hall, 53095 Main Road
TOWN CLERK A' �� P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(631)765-6145
MARRIAGE OFFICER4 �,; Telephone(631)765-1800
RECORDS MANAGEMENT OFFICERS "" 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: July 12, 2018
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4627 for a Cesspool/Septic Tank Construction
Permit submitted by:
Nancy Dwyer for Sara Belleshei .
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 fi-oni, the Suffolk Coupty l lealth Department
Signature
Dated
ELIZABETH A.NEVILLE Town Hall,53095 ain Road
TOWN CLERK R0.l3ox 11M79
C4 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OFT 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. 9W7
Permit No------
Applicant Name ................. L
Applicant Mailing Addiess go L)4ILo Id
.............. m.
Septic Tank ---or Cesspool
Brief escri non of Proposed Construction or Alteration
.............
Location of Proposed Construction/41teration:
Owner of Property:_..... '-° et(a,e63A-k
Owner Mailing Address:.
V700, NY 10703
Owner Property Address::::
tL ............
Name and phone number of contact person Ovmc
Tax Map No: 0'01) Section a<<q Block Lot =�2
Cross Street
...........
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WIT ry EALTH DEPARTMENT APPROVAL
_2 i
Signature of A plic Date
Received by: . ...........
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