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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.southoldtownnygov
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: January 14,2019
RE: Cesspool Construction Application
Transmitted herewith is a copy of application No. 4691 for a Cesspool/Septic Tank Construction
Permit submitted by:
Halsey G.Tuthill.
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 required from the Su&Ik CauntY Itzahh L7enatKment
Signature
Dated
_0P
S�F FOJ 4,
ELIZABETH A.NEVILLE Town Hall,53095 Main Roo.
TOWN CLERK Q P.O.Box 1179
REGISTRAR OF VITAL STATISTICS
Southold,New York 11971
MARRIAGE OFFICER Fax(631)765-6146
RECORDS MANAGEMENT OFFICER Telephone(681)765-1800
FREEDOM OPIKFORMATION OFFICER southold(own.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF`SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential g$104 or Non-Residential @$25 Application No.
Perinit W
Applicant Name
I-,
Applicant.Mailing Address
Septic Tank
� or Cesspool
Bricf`D —
,=ription of Construction or Alteration 'Pk'v_"
Location of Proposed Construction/Alteration:
Owner
Owner Mailing Address
Owner Property Address*
Name and phone number of contact person
Tax Map No: Section— Block Lot
Cross Street
NOTE: LOCATION MAP MUST-BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signaiwe of
by;
Date
Received hy
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SANITARY PLAN
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