HomeMy WebLinkAboutAndrejack, Thomas g�F F04
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JUDITH T.TERRY � _ Gym Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
v Southold, New York 11971
REGISTRAR OF VITAL STATISTICS p MARRIAGE OFFICER �� y 1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER __ ,( 1111 ��0111 Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1609 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : THOMAS ANDREJACK
Address 1 : P. O. BOX 349
City St Zip CUTCHOGUE NY 11935
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-96-0113
Name Of Owner ANDREJACK, THOMAS
Mailing Address 1 P. O. BOX 349
City St Zip CUTCHOGUE NY 11935
Property Address 1 305 OLIVIA LANE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 83.00 block 4 lot 5.000
Cross Street DUCK POND ROAD
Building Permit Number Cross Reference:
Issue Date: 3/20/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• t
�,,o��S�F FOL,•649 097
JUDITH T.TERRY ��� 1 Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
v•• " i Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER :�yif' e / Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER �.� * i)40,00Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER 2zzzrcru���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: January 17, 1997
Transmitted herewith is a copy of application No. 1662 for a Cesspool/
Septic Tank Construction Permit submitted by:
Thomas Andrejack •
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.
vXct‘z,
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE
DISAPPROVE
Comments:
RECEIVED
2 r) 1997
MAR Signature 7)
outho d Town ` ,K�, i///P7
Dated
« y
OFFICE OF THE TOWN CLERK ( `'"
Town of Southold Application No./ .2
• •3 :
Judith T. Terry, Town Clerk
Town Hall, 53+895 Main Road Construction
P. O. Box 1179 Alteration
Y •,
Southold, New York 11971
Tete hone � + $10.00 - Residential ✓
P
(516) 765-1801 °` $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE //(7/ 7
APPLICANT NAME: /� A-0-5
APPLICANT ADDRESS: PO foic 3 V9
y l 1 q 3S—
SEPTIC ,CESSPOOL ✓
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTER/ A/ TION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: 36 S- D L wig L
1
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section 83 Block 6 11 Lot
CROSS STREET: D AGI 0 ,4 �QO`
BUILDING PERMIT NUMBER CROSS REFERENCE:
‘.14uc-6
Signature of App ant
RECEIVED BY: /C %-
f own Clerk's Office
DATE: / I/ 7 C
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TH
\ FFDR APPROV�oF�cONSTRUcTl of Y VICES
OF
HEAL.
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'VII. B 6t:1q1L s DATENO.Ms REF. .•
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17 o
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Si APPROVED
F The water supply and sewage disposal
.-. systems for this residence will conform -, i
\\ y\00� `O� to the standards of The Suffolk County
• Department of Health Services.
\ .
\ O N 1 WATER SuyrLY AND SEWAGE DEPOSAL SYSTER4S MUST
'• �'f. i A. •••7,\ CONFORM WITH NEIN S'TA.NDARDS DAT$D NOVEWBER.13,1495.
ss 2 Q
�a 0 \., *ON SURVEY OF
0.? �""°�M�� \`�a , py cxe. L O/ 5
tIO
° "MAP OF WOODBINE MANOR"
', 4* `s, cS� FLEDAS99
°a, ,,e a '� AT CUTCHOGUE
TOWN OF SOUTHOLD.
? h,' Q. SUFFOLK COUNTY, NY.
S' 4 ,. 1000-83-04 -05
AREA =40,857 sq ft. If\ _�`' Scale • f"- 40'
/ �, �d `�' - 60• • 3 0 0July 26, f993
a a \00. -
CERTIFIED T0+ ' 710cP64e.
�. oTHOMAS ANOREJACK �' :;uTiO4,;..uNrf DEPAit1MENT OF REALTH SERVICES aCATHERINE L. AtCREJACK y\•O .0 't
€"s• III T FOR ATONAL OR CONSTRUCTION FOR A
Q T3 S. SiIIGLE FAMILY RESIDENCE ONLY _�_7
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