HomeMy WebLinkAboutPiechnik, Dariusz ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORM-,kTION OFFICER
TOWN OF SOUTHOLD
i TO'row, ~ ')~ 5?S-~d00~Tc vn Building Department
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax {631) 765-6145
Telephone (6311 765-1800
southoldtown.nor th fork.net
FROM:
Linda J. Cooper, Southold Town Clerk's Office
DATED: April 6, 2005
Transmitted herexvith is a copy of application No. 3452
Permit submitted by:
for a Cesspool/Septic Tank Construction
Joan Chambers for D. Piechnik
Please reviexv 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 fomi below and return it to me.
Linda J. Cooper
I have reviexved the application and location map of the project cited above and make the following
recommendations: j
APPROyrE
DISAPPROVE
Conwnents: ~
ELIZABETH A. NEVH.LE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 v' or Non-Residential ~ $25 __
Applicant Name
Applicant Mailing Address
Septic Tank ,/ or Cesspool
Brief Description of Proposed Construction or Alteration
Application No.3C~ ~
Permit No.
Location of Proposed Construction/Alteration:
Owner of Property: ~."D cfr- ~ o
Owner Mailing Address: '~-0 . ~o x...:~
Owner Property Address:
Name and phone number of contact person ~)a.c( ,~8~ '~ ~'e~ ~-x ( &
Tax Map No: Section ,5~..~ Block O Z~ Lot
Cross Street { M LEfT aO3tOD to.. ~> .
NOTE: LOCATION MAP MUST BE SUBI~HTTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Sign~e of Applicant Date
Received by:
IN~T POND ROAD
L~3T 70
N (~VELLING VITH ~.I~LIC VATER)
FC
! ~m F~miitQr with %he STANDARDS FOR APPROVAL
AND CONSTR~TIDN ~ SUBSURFAc~ SEWAGE
DISPOSAL ~Y~TENs FOR SINGLE FAMILY RESIDENCES
on the permi~ to construct.
~e Ioce~ion o~ we{Is end Cesspoots sho~m hereon ~re
F~om Fle{d observations ~nd or do~ obtained F~om O~bers.
I=~NUNENT AREA=20,317 S,F.
LOT NUNBERS REFER TO '
SHOREs - SECTION TVO'
SUFFOLK COUNTY CLERK'S
ND. 4426,
SURVEY OF PROPERTY
A T GREENPOR T
TO,tN OF SOUTHOLD
SUFFOLK COUNTY, NE~r YORK
1000-33-0~-09
SCALE: 1"=30'
AUG. 26, 2002
SEPT. /~, 2002 ( certificaflo~ ,I
tSURANCE
~ EA$ TERN
~ IN Tt4E
ICE ,45 t4,4P
%.k,..; .%,,;.~ /
hlC. NE1. 49618
/ PECUNIC ~L~9'EY~R~,
(631) 765 - 5020 FAX~(631) 765-1797
P, 0. B~X 909
1230
TR,4 VELER
STREET