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Home My WebLink AboutPawluczyk, Bertha • ��FFOLkCO • *,"a, •• Town Hall, 53095 Main Road ,4,�O O�f P.O. Box 1179 11111 .�1D a Southold, New York 11971 JUDITH T.TERRY . TELEPHONE TOWN CLERK (516) 765-1801 REGISTRAR 01 VITAL STATISTICS OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT CONSTRUCTION OR ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. 1578 R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X PERMIT ISSUED TO: Name : PECONIC CESSPOOL Address 1 : P. O. BOX 972 City St Zip MATTITUCK NY 11952 Descripton of Proposed Construction or Alteration REPLACE OLD CESSPOOL WITH NEW TYPE. APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS BUILDINGS, PROPERTY LINES, AND WATER BODIES. EXCAVATION INSPECTION REQUIRED. Name Of Owner PAWLUCZYK, BERTHA Mailing Address 1 ROUTE 48 City St Zip CUTCHOGUE NY 11935 Property Address 1 ROUTE 48 City St Zip CUTCHOGUE NY 11935 Tax Map No. section 85.00 block 5 lot 4.000 Cross Street BRIDGE LANE Building Permit Number Cross Reference: Issue Date: 12/12/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) 0.,O\OS�FFO(�-00G, JUDITH T.TERRY itsyt Town Hall, 53095 Main Road TOWN CLERK ; N Z P.O. Box 1179 Southold, New York 11971 REGISTRAR OF VITAL STATISTICS %%%1 � ,�� Fax (516) 765-1823 MARRIAGE OFFICER � �f� .a�,'�� Telephone(516) 765-1800 RECORDS MANAGEMENT OFFICER 1 �► FREEDOM OF INFORMATION OFFICER '••~ os,i OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TO: Southold Town Building Department FROM: Linda Cooper, Southold Town Clerk's Office DATED: December 10, 1996 Transmitted herewith is a copy of application No. 1647 for an ALTERATION PERMIT for a cesspool or septic system submitted by Peconic Cesspool for Bertha Pawluczyk 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 this office. Thank you. Linda J. Cooper * * * * * * * * * * * * * I have reviewed the application and location map of the project listed above and make the following recommendation: APPROVE - DISAPPROVE - COMMENTS: Maintain required setbacks from adjacent wells, buildings, property lines and water bodies. EXCAVATION INSPECTION REQUIRED. ":; ignatur- /� /i Cj6 Date CE OF THE TO CLERK �,,� ' Town of Southold _ 6-9 Judith T. Terry, Town Clerk ,' �� l/y; Application N Town Hall, 53095 Main Road Cons uction P. O. Box 1179 Z ; l n Southold, New York 11971 y /�,' Alteratio ` Telephone ,f �� r�' $10.00 - Residential,_ (516) 765-1801 --. ..� r � / ,� $25.00 - Non-Residential C/ TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. Fee $ DATE Zv* APPLICANT NAME: 6 /—°4//11-4,� APPLICANT ADDRESS: /fid 601 17'2— L SEPTIC CESSPOOL ✓ DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATIO OWNER OF PROPERTY: _ Z 71 OWNER MAILING ADDRESS: OWNER PROPERTY ADDRESS: TELEPHONE NUMBER OF CONTACT + PERSON: )'r 5' TAX MAP NO. : Section s Block Lot V CROSS STREET :` _�� BUILDING PERMIT NUMBER CROSS REFERENCE: Signature o Applicant / FECEIVED BY: Town Clerk's Office DATE: h,,Lspz IY/114 s_s 5j` 12-1/- � IA)