HomeMy WebLinkAboutShipman ELIZABETH A. NEVILLE, MMC � ��'� p9� W Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � r �� Fax(631)765-6145
MARRIAGE OFFICER phone
Ww � �1I�V Tele 765-1800
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RECORDS MANAGEMENT OFFICER � � m>i� 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: October 3, 2018
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4659 for a Cesspool/Septic Tank Construction
Permit submitted by:
William Shipman
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
Town of Southold
P.O Box 1179
Southold, NY 11971
* * *
RECEIPT * * *
Date: 09/28/18 Receipt#: 248717
Quantity Transactions Reference Subtotal
1 Septic Permit-Construct- Resid, 4659 $10.00
�. Total Paid: $10.00
Notes:
Payment Type Amount Paid By
CASH $10.00 Shipman, Bill & Beth
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Shipman, Bill & Beth
P O Box 1315
75 Horseshoe Dr.
Cutchoque, NY 11935
Clerk ID: JENNIFER Internal ID:4659
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ELIZABETH A. NEVILLE Town Hall, 63095 Mein Rog,
TOWN CLERK czz P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6146
RECORDS MANAGEMENT OFFICERt Telephone(631) 765-1800
FREEDOM OF iivFORMp.TION OFFICER ] southoldtown.northfork.net
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, ..
Perinit No.
Applicant Narne WiNneA IAIcnrVJ
Applican(Mailing Address
Septic Tank- or Cesspool
p � /I
Brief Description of Proposed Construction or Alteration ° _ ,w
Location of Proposed Construction/Alteratioa:
Owner of Property. y 1+ °; y° . ,
Owner Mailing Address: 1.3ov, i
Owner Property Address: j - )°k)rei
Name and phone number of contact person
TaxMapNo: jt&o Section Block Lot `ge
Cross Street
NOTE: LOCATION MAP MUST'BE SUBM[TTED WITH APPLICATION. NEW
CONSTRUCTION RE'QUERES SURVVY WITH HEALTH DEPARTMENT APPROVAL
RECEIVEDA
I/ es
Signature of Applicant Date
SEP
1 coo ved by: _ _.... _.
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SUFFOLK CO. HEALTH DEPT. APPROVAL._
M. S. NO. 860
q res.)
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-. . STATE ENT Or I NLI� T
THE WATER SUPPLY AND SEWAGE DISPOSAL:
C SYSTEMS FOR "THIS RESIDENCE WILL „
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x � CONFORM TO THE STANDARDS OF THE
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SUFI=OLK CO. DEPT. OF HEALTH SERVICES.
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APPLICANT
SUFFOLK COUNTY DEPT. OF HEALTH
$ERV ICES — FOR APPROVAL OF
CONSTRUCTION ONLY
Y
Area : 40, 41.8 6 f. DATE:
H. S. RE"F. NO.:
APPROVED: -- - —
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SUFI=OLK CO. TAX MAP DESIGNATION:
DIST. SECT. BLOCK PCL.
110,0D 094T l4 ".
OWNERS ADDRESS
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