HomeMy WebLinkAboutWloolzimierz, Wisor
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ELIZABETH A, NEVILLE
TOWN CLERK
Town Hall, 53095 Main Road
P,O, Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown,northfor k, net
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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'''-- - 1\ II, \ OFFICE OF THE TOWN CLERK
FEB I 0" ! . , TOWN OF SOUTHOLD
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$~uthold TciWll-llhilding Department
FROM:
Michelle 1. Martocchia, Southold Town Clerk's Office
DATED:
Febmary 9, 2006
RE:
Cesspool ConstmctionlAlteration Application
Transmitted herewith is a copy of application No, 3565 for a Cesspool/Septic Tank
ConstmctionlAlteration Permit submitted by:
Wloolzimierz Wisor
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,
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I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
/
DISAPPROVE
Comments:
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Signature
t!)~ ~o /0 6
Dated t' /
,
ELIZABETH A. NEVILLE
TOWN CLERK
, REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
__,Town Hall, 530915 Main Road
P.O, Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
sou tholdtown, northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10-4 or Non-Residential @$25_
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Application No,3~ b:)
Permit No.
Applicant Name Wlod"zllYiren WI$Og,
Applicant Mailing Address 8.S -yo Au. J -t" III if fl-pf. e e-
tf.ew G-oil.qe ns I Ny 11~{0
Septic Tank_or Cesspool_ 0 .L
Brief Description of Pro posed Constmction or Alteration tlh ((1J '411'!1r ~
'3 IKJedIfOOW. r,0J1.16
Location of Proposed Constmction! Alteration:
Owner of Property: W /oc/z,/m/en W J.s. 012-
Owner Mailing Address: 8!:' -YO -AuJH.u J+ /hot, 2/2.
~ ~vde,l.S I NY I/t;/J-
Owner Property Address: I:z. 0'0 ?> Ofyv/e u.; A-vQ,
. SO~J:lfMJlq I NY 1/97/
7/B-Sr7J -3~o8
Block 0 S'
{jJ I S. oR-
ft.9
Name and phone number of contact person
Tax Map No: {(JOG Section 5 'L
Cross Street w!o/) '! f,tf)
NOTE: ,LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEP ARTMENT APPROVAL
ht'JvJL ~/gJJoo6
Lot
Signature of Applicant
Received by:~Q/t ~
Date
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