HomeMy WebLinkAboutPavlak, Florence /'y %
:c Town Hall, 53095 Main Road
•
JUDITH T.TERRY tt�=� .
TOWN CLERK ; y = ; P.O. Box 1179
,1 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax*.I Fax (516) 765-1823
MARRIAGE OFFICER ;_4 ��0 �� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER J�L �,�f°
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. 1522 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : EAST ISLE CUSTOM BUILDERS INC.
Address 1 : 278 JAMAICA AVENUE
City St Zip MEDFORD NY 11763
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. #R10-96-0064
Name Of Owner PAVLAK, FLORENCE A.
Mailing Address 1 C/O EAST ISLE CUSTOM BUILDERS
278 JAMAICA AVENUE
City St Zip MEDFORD NY 11763
Property Address 1 3755 GRAND AVENUE
City St Zip MATTITUCK NY 11952
Tax Map No. section 107.00 block 1 lot 5.002
Cross Street GRETON COURT
Building Permit Number Cross Reference:
Issue Date: 8/12/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY _< Town Hall, 53095 Main Road
TOWN CLERK ti Z P.O. Box 1179
Wa 0 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1, 1Fax(516) 765-1823
MARRIAGE OFFICER =-fo a00' Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER 1 �► ,
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: August 5, 1996
Transmitted herewith is a copy of application No. 1588 for a Cesspool/
Septic Tank Construction Permit submitted by:
East Isle Custom Builders for Florence A. Pavlak
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 (� l)
Comments: 4,,w.-crir../..e.re) v�� -�' ed-7‘ - rJ
-
411
Signatur
E
Date
.a.
OFFICE OF THE TOWN CLERK ,,,,,,,,,,,,,,,,,
Town of Southold ;' � E4 = 1588
Judith T. Terry, Town Clerk ;���J C�l/� Application No.
Town Hall, 53095 Main Road Construction x
P. O. Box 11791711 _
Southold, New York 11971 Alteration
Telephone O,jy ���',� $10.00 - Residential x
(516) 765-1801 = l �,��'� $25.00 - Non-Residential
-- -"I,,,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME: East Isle Custom Builders Inc.
APPLICANT ADDRESS: 278 Jamaica Avenue
Medford NY 11763
SEPTIC CESSPOOL x
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
New Single Family Dwelling
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
• OWNER OF PROPERTY: Florence A. Pavlak
OWNER MAILING ADDRESS: c/o builder
OWNER PROPERTY ADDRESS: 3755 Grand Ave
Mattituck, NY 11952
TELEPHONE NUMBER OF CONTACT PERSON: c/o 727-6023
TAX MAP NO. : Section 107 Block 1 Lot 5.2
CROSS STREET: across from Greton Court
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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