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1 ELIZABETH A. NEVILLE,MMC Off' 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 ,fr Off. Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER O,( �`1 www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD D �j
TO: Southold Town Building Department AUG 7 2018
FROM: Sabrina Born, Southold Town Clerk's Office BU LDINGDLW.
TOWN OF SOUTHOLD
DATED: August 2, 2018
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4635 for a Cesspool/Septic Tank
Construction Permit submitted by:
Elizabeth Liebert
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 Y
Comments: 12�� -
Signature
Z/511195
Dated
r
ELIZABETH A. NEVILLE, MMC t Town Hall,53095 Main Road
TOWN CLERKP.O.Box 1179
m 4 Southold,New York 11971
to
REGISTRAR OF VITAL STATISTICS , Fax(631)765-6145
,
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER � � ���Pi www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICERS „ �
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Sabrina Born, Southold Town Clerk's Office
DATED:. August 2, 2018
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4635 for a Cesspool/Septic Tank
Construction Permit submitted by:
Elizabeth Liebert
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 _vv�.
ELIZABETH A. NEVILLE "
,�, � '�� Town Hall, 53096 Mein R.oa,
TOWN CLERIC P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �,v
Southold, New York 11971
MARRIAGE OFFICER " �� Fax (631) 765-6146
RECORDS MANAGEMENT OFFICERTelephone (631) 766-1800
FREEDOM OF INFORMATION OFFICER southoldtown,northforlc.net
4
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residdntial @$10 or Non-Residential @$25 Application No. ..
Permit No.
m
Applicant Name '
Applicant Mailing Address.®
Septic Tank- or Cesspool
Brief Description of Proposed Construction or A
Location of Proposed Construction/Alteration:
Owner o,
f Property. Y. VIA"
Owner Mailing Address
Owner Property Address: _ > �
Name and phone number of contact person �°� ,; ��,�°
Tax Map No: Section.—6UL block Lot 6�1,
Cross Street
NOTE: LOCATION MAP MUST'BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURV19Y WITH HEALTH DEPARTMENT APPROVAL
Sllnure;` f Applicant ate
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