HomeMy WebLinkAboutCampbell ELIZABETH A. NEVILLE, MMCF � � �'° �
��,� Town Hall,53095 Main Road
TOWN CLERK � � P.O.Box 1179
' r Southold,New York 11971
REGISTRAR OF VITAL STATISTICSr ° Fax(631)765-6145
MARRIAGE OFFICER � 5 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: October 19, 2018
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4666 for a Cesspool/Septic Tank Construction
Permit submitted by:
Irian Campbell.
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 a-eco uii ed from the Suffolk Count Health Department
Signature
.....-. _....................
Dated
ELIZABETH A. NEVrLLE " ' Town Hall,63096 Main Roa.
TOWN CLERK e P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER . Telephone(631) 765-1800
FREEDOM OF 1N ORMATMN OFFICER so utholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERAUT
CESSPOOL or SEPTIC TANK
Residdntial @$10_ „ or Non-Residential @$25 Application No.
Permit No.
ApplicantNar e _........._
Applicant Mailing Address
Septic Tmik-_: " or Cesspool
Brief 1 pLot .. , � � 0 a D
on or At eratio
Description of Proposed Decd �Costctl
ooL,
Location of Proposed Construction/Alteration:
Owner- of Property:
tA
Owner Mailing Address: . t
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Owner Property Address-, w� F
ry
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Name and phone number of contact person_
Tax Map No: Section '7-1.m Block Lot
Cross Street E
NOTE: LOCATION MAF MUST'BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES S'UB.VV H HEALTH DEPART NT APPROVAL
---Lodi �-,
Signature of Applicant Date
Received by
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