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JUDITH T.TERRYy1\� Town Hall, 53095 Main Road
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TOWN CLERK y Z P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS y Fax (516) 765-1823
Fax Southold, New York 11971
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER O!IJ '�►a,. 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. 1718 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : JANINE PELLICANO, J. BAKANIC
Address 1 : 359 PENNSYLVANIA AVENUE
City St Zip BAYSHORE NY 11706
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. REF #R10-97-0122
Name Of Owner PELLICANO, RUSSELL A.
Mailing Address 1 359 PENNSYLVANIA AVENUE
City St Zip BAYSHORE NY 11706
Property Address 1 9680 NORTH BAYVIEW ROAD
(LOT 4 OF PELLICANO WOODS)
City St Zip SOUTHOLD NY 11971
Tax Map No. section 79.00 block 8 lot 13.000
Cross Street SEAWOOD DRIVE
Building Permit Number Cross Reference:
Issue Date: 8/25/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
7 77J7
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y
JUDITH T.TERRY � _ Town Hall, 53095 Main Road
TOWN CLERK o i P.O. Box 1179
t yy. IIISouthold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER : y 1�
RECORDS MANAGEMENT OFFICER Telephone (516) 765-1800
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 15, 1997
Transmitted herewith is a copy of application No. 17$9 for a Cesspool/
Septic Tank Construction Permit submitted by:
Janine Pellicano and John Bakanic for Russell Pellicano
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 reco mendations:
APPROVE
DISAPPROVE
Comments:
Signa e
X10 0/97
Dated
.
�
0FF1C :: OF |HE TOWN CLERK
06,Town of Southold
Judith T . Terry' Town Clerk Application No. //
Town ||aU 53095 Main Road ^ ��
' Construction
P. O. Box 1179 Alteration
---'�---
Southold, New York 11971
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� Reuidena| ��
Telephone ^�x
(516) 765-1801 ~�nz/*p' Non- Residun(ia\
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TOWN OF SOUTH0LD
SOUTIIOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Pet-mit No.
Fee $___________
DATE
---'-----------------------------'
APPLICANT NAME : ---3Z1 "r-N 1--)gli C
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/\|"|`L|CANT ADDRESS: ��
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3EPT|CESSPU0L
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PESCR|PT|ON OF PROPOSED CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must he attached hereto Before pet may he issued.
• LOCATION OF PROPOSED CONSTRUCTION ALTERATION :
OWNER OF PROPERTY : --Rlass \ J( \ �
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OWN ER MAILING /\D DR ES S: 3,S9R6nrISA/FIrN _
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UVVNER PROPERTY ADDRESS : 61
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TE|EP|0NE NUMBER OF CONTACT PERSON :
FAX MAP NO. : Section 7 �� Nod� «� Lu( ��
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[|<0SS 5lREET :
BUILDING PERM[[ NUMBER CI
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�/yoaiur°a (c( Applicant
RECEIVED /V
Town Clerk~� Office
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DATE : Vl-'-�_-__-~_-_--_-_---___
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THE EXSTENLE•OF RIGHTS OF WAY 1--- a
ANO/OR EASEMENTS OF RECORD IF-
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ANY. NOT SHONN ARE NOTcv
GUARANTEED. \ N LOT No. 4 N
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UNAUTHORIZED ALTERATION OR ADDITION \ 2.44 ACRES '
TO THIS SURVEY IS A VIOLATION OF \
SECTION 7209 OF 1HE NEW YORK STATE
EDUCA71Q4 LAW.
COPIES OF 1115 SURVEY MAP NOT BEARING . \N.
THE LAND SURVEYORS AVKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED N
IT)BE A VAGD TRUE COPY.., N.
GUARANTEES INDICATED HEREON SHALL RUN
OA.Y TO THE PERSON MR INIOM THE SURVEY _ 69 r "
IS PREPARED.AON MS BEHALF TO THE
NO N 26 50 W 253.23'
TITLE COMPANY. GDIERTVI•NTAL AGENCY AND -
LENDING EVSTTTU7101 LISTED HEREON, AND LAND NJF OF ARSON
TO THE ASSIGNEES OF THE LENDING NVSPP- \
1URON. GUARANTEES ARE NOT TRANSFERABLE. ,
SURVEY OF: DESCRIBED PROPERTY,
ALSO KNOWN AS LOT No. 4oh.�u+lomod KENNETH, H._BECKMAN. L.S..
SUBDIVISION OF PELLICANO ODSg camH 8t>arte�M� end Land Planfniar i
SITUATED IN: '' BAYVIEW' AUG 15 1997 _ 8 Expreim►p.Drive South, '
TOWN'OP: SDU7HOL0 . - t Of Health ServMa. ....00�Al ��' ;. nkonkoma,.NI. 11779
• SUFFOLK COUNTY. NEW YORK • o"fOsOtw� � ,• # 3% ale bee-os8o ,'
. i .,1 ' 1►A4 Ole) 487.8941 r
DATE 4/7/97. JOB.,NO. 97-"2737':, SCALE. 1' a 6d' ',..4,64? A i }'
bis'r SEC 3 'BLK LOT F,<.°49" 04° x
S.C.IIM NO. 1000. 'Q79 170 08 I5/1% 13 T '
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