HomeMy WebLinkAboutBzezinski, John 111'0004
JUDITH T.TERRY _ 1• Town Hall, 53095 Main Road
TOWN CLERK ; y = ; P.O. Box 1179
0 1,� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ; if� _,%! o Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER •_ 0.( `�► ��i 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 r CESSPOOL
Permit No. R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : JOHN R. BZEZINSKI
Address 1 : 17 TACOMA LANE
City St Zip SYOSSET NY 11791
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-95-0126
Name Of Owner BZEZINSKI, JOHN AND KAREN
Mailing Address 1 17 TACOMA LANE
City St Zip SYOSSET NY 11791
Property Address 1 KENNYS ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 54.00 block 5 lot 23.000
Cross Street LAKE DRIVE
Building Permit Number Cross Reference:
Issue Date: 5/06/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,
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,,/°(o\V �FFO��coG, j 114
JUDITH T.TERRY % o= .fit t Town Hall,53095 Main Road
TOWN CLERK t H Z P.O.Box 1179
REGISTRAR OF VITAL STATISTICS G "V # Southold,New York 11971
MARRIAGE OFFICER : ylf� 0-i Fax(516)765-1823
RECORDS MANAGEMENT OFFICER 49.( * `0„.. Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ��.... 0
1.8
OFFICE OF THE TOWN CLERK �`\.-
TOWN OF SOUTHOLD Q C5 Q �r
TO: Southold Town Building Department `,lY -,
J 1996
FROM: Linda J. Cooper, Southold Town Clerk's Office '"",,
,.., 5t 0�
DATED: May 3, 1996 )c !ii-
,.., R
Transmitted herewith is a copy of application No. 1536 for a Cesspool/
Septic Tank Construction Permit submitted by:
John R. Bzezinski •
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE
DISAPPROVE
f
Comments: ". ""^A.:4Cie 0. # c-2:v �• / - .961
,- Ale' i 4IP
ignatur
Da •d
OFFICt OF THE TOWN CLERK ••"""'"
Town of Southold • •�FFD�k r •
Judith T. Terry, Town Clerk 5 Application No.
Town Hall, 53095 Main Road t
Construction
P. 0. Box 1179 Alteration
Southold, New York 11971 • .�;'
Telephone ,//J� Ari $10.00 -Residential
(516) 765-1801 _'K i' 525.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
. APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Permit No.
Fee 'S
DATE PIA f2C41 -5 996
APPLICANT NAME: JDl.J•N 14,544
APPLICANT ADDRESS: ii -0 441,44
N .y- 1V7
SEPTIC ✓CESSPOOL ✓
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
• 11 L !
•
LOCATION MAP: •'Must be attached hereto before permit may be Iesued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: ,
OWNER OF PROPERTY: , _ �1. i 137,42,1745g1
OWNER MAILING ADDRESS: I"} Q 44. .
_ •.y .
OWNER PROPERTY ADDRESS: NKEy%. (25). 1 S,,1'F' kaP
TELEPHONE NUMBER OF CONTACT PERSON: ( 1 ) •c I 4994
TAX MAP NO.: Section 054 Block 5 Lot 2,3
CROSS STREET: Q • • !Jt* A A ,t Ca)
!WILDING PERMIT NUMBER CROSS REFERENCE:
gnature o cant
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RECEIVED BY: irAW Ark!
'•wn • ce
DATE: \ter , 7-L4 _;.__r__-
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SUFFOLK CO-HEALTH DEPT.APPRO VA4.
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