HomeMy WebLinkAboutKlieber ELIZABETH A. NEVILLE, MMC ��� �� x Town Hall,53095 Main Road
TOWN CLERK �` P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ��„ w �i, Fax(631)765-61455
Telephone(631)765-1800
RECORDS MANAGEMENT OFFICERS �'"VIII � ,�� 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: November 14, 2018
RE: Cesspool Construction/Alteration Application
Transmitted herewith is a copy of application No. 4677 for a Cesspool/Septic Tank
Construction Permit submitted by:
John Kleiber
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
C
ELI ETR A. NE LE Town Hall,53096 Main Roa.
TOWN CLERK @ P.O. Box 1179
REGIST OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER r Fax (631) 765-6146
RECORDS MANAGEMENT OFFICER +ff� j Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER � Psoutholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERffT
CESSPOOL or SEPTIC TANK
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or Non-Resential $25 Application Residential @$IO �, � @ pp cation No.
Permit No.
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Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address. �� �
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Owner Property Address---2r�"" 1 ti m
Name and phone number of contact person Jtx m
Tax Map �t
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NOTE: LOCATION MAP MUST'BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVVY WITH HEALTH DEPARTMENT APPROVAL
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Si late r" of Applicant Date
Receivedby: .........._.....�...._-.._ �_....._...
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„.: RES ARE FOR A SPECIFIC PURPOSE AND ARE NOT TO BE USED TO P.STAN4l'.xIM 1@R'CP+ENCTY INC$OR FOR F.FFbkO:DJQ CF Fk WOE»...(T"A[OWNERS TMIS THEY LOCATION OF SWELLS(W),N°.*T11TIZ'GTANKS((ST S&INKED
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ESER
TFlCATIONS ARE N08 1RAN'�.aF§RAW.E'FTti ADDITIONAL IH.,x tldTUTION�OR S1iD."eEIMdRT'
400 Ostrander Avenue, Riverhead, New York 11901
631.727.2303 fax. (o31.727.0144
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