HomeMy WebLinkAboutWickham ELIZABETH A. NEVILLE,MMC 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 " �� .�� Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER ' 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 31, 2018
Transmitted herewith is a copy of application No. 4672 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Stacey Wickham
Please review the application and location map and advise if the project has received Suffolk County
Health Department approval and 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. Maintain t qr fired setbacks fl� clj c+ rat ll , l a lc l s, pr p a r...ITJJJJcs and water
Bodies. EXCAVATION INSPECTION REQUIRED,
Signature
Date........._ ......_
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ELIZABETH A. NEVILLE Town Hall, 63096 Main Roa.
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS r
MARRIAGE OFFICER m Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER � r Telephone(631)766-1800
FREEDOM OF! FOR.MATION OFFICER - r" so utholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
S O UTHO LD WASTEWATER DISTRICT
APPLICATION
CO NSTRUCTIO N o r A.LTERATIO N PERMIT
CESSPOOL or SEPTIC TANK
Residdntial @ W-K- or Non-Residential t7a $25 Applic,a(iorl No.
Applicant Name
Applicant Mailing Address 0 8 �
"0l(,LA,4 1 q,
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Septic Tank- or Cesspool
.. _ ��� . � 2A�',,,,,Fration Brief D scri tion of Pro.Ised onst ct"on o
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Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address. `"
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Owner Property Address:
Name and hone number of contact person �` "fit ��� �� �`t, . '
Tax Ma Section lock t
P No: �0�
Cross Street
NOTE: LOCATION MAP MUST-BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY NWITH HEALTH DEPARTMENT APPROVAL
16 kj I
. Stglaatu, of Applicant Date
Received by: ...._ .._ _....._.
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