HomeMy WebLinkAboutPiechnik, Dariusz (2) SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3308 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : JOAN CHAMBERS
Address 1: PO BOX 49
City St Zip SOUTHOLD NY 11971
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 #R10-02-0192
Name Of Owner PIECHNIK, DARIUSZ
Mailing Address 1 PO BOX 1868
City St Zip SOUTHOLD NY 11971
Property Address 1 575 WESTWOOD LANE
City St Zip GREENPORT NY 11944
Tax Map No. section 33.00 block 2 lot 9.000
Cross Street INLET POND LANE
Building Permit Number Cross Reference:
Issue Date: 5/18/05 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ill .
•
,,,,_, sour*- 3 3 07<
ELIZABETH A. NEVILLE 1,0,40 �<4 ; Town Hall, 53095 Main Road
TOWN CLERK , * * , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ` N Southold, New York 11971
MARRIAGE OFFICER �p g1�, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER Ol. A �0 Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER =�COU ,��,��� southoldtown.northfork.net
,��' '�' 1#J
, OFFICE OF THE TOWN CLERK
iDU APR - 6 1 TOWN OF SOUTHOLD
l TO---w; tSo igld TJown Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: April 6, 2005
Transmitted herewith is a copy of application No. 3452 for a Cesspool/Septic Tank Construction
Permit submitted by:
Joan Chambers for D. Piechnik
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
1
OF
Comments: l ���,._ _
. _lir
, ,
IllOP
iIIV
Signature
Date
o�gOFF04
ELIZABETH A.NEVILLE �`�' '3 Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
REGISTRAR OF VITAL STATISTICS o �� Southold,New York 11971
MARRIAGE OFFICER : 0 ��� Fax(631) 765-6145
`
RECORDS MANAGEMENT OFFICER sir Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER :6'1 lig it's southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 /or Non-Residential @$25 Application No.-3L6
Permit No.
Applicant Name JOA C �kmeER-3 CZ `�- .pt
C Cl{N
Applicant Mailing Address 1 C) BOX
SOO tc,LO r3 ( wril
Septic Tank V or Cesspool ✓
Brief Description of Proposed Construction or Alteration 1\ek,J 5 itig�Q -u�w►��
feed) id e.A CD
Location of Proposed Construction/Alteration:
Owner of Property: a 'i tJ s2, k r t
Owner Mailing Address: T-O - goV ( S(og (5O 1k111.o1c(
Owner Property Address: 5 7 5 ( kks-k- . O o& L-c(ivt€
Name and phone number of contact person b ct vS2, p 6 2C.\Y1 t rC 4-7 -d G 627
Tax Map No: Section 33 Block 0 2 Lot C)'
Cross Street INE ToN) (1Z)
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
4 .6-U
Sign a of Applicant Date
Received by:
• INLET POND ROAD
W
cA
4
LOT 70 g
(DWELLING WITH PUBLIC WATER)
FE
150.00' 0.414
0.3'W
a41r N 86.07'00' E _�-- .__ _ - EL.
0.41E EL. 18.0' t/1
W, 'N
EL. 17.r tri i} bi
LOT 69 1 1 w
5 � is �.
yi '' 1"' W W 4 5°.
1u' o \ ,
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1'1
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£L.
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t I
60
69.°241 t..0!,..$1)
fir' S
g CER TEED TO'
OARIUSZ PI!l t:J'+YwN+K
BEA TA W 'WSZKOWJCZ
FIDELITY NA TIONAL TI
COMPANY OF NE YORk
WA silos TON MUTUAL
NEITES:
I am familiar with the STANDARDS FOR APPROVAL
AND CONSTRUCTION OF SUBSURFACE SEWAGE
' DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES
,and will abide by the conditions set forth therein and
on the permit to construct. LOT NUMBERS REFER TO '
SHORES - SECTION TWO'
The location of welts and cesspools shown hereon are SUFFOLK COUNTY CLERK'S
fr'om field observations and or data obtained from others. ND. 4426.
Elevations are referenced to an assumed datum, ANY K.traOrr OR Asorraw TO nos so
OF EXCEPT
As I SAlearms 7aP -smac a.
8=MONUMENTMOM ""e rat ?MS AMP Mii
VMSE SIONATURC MOWS MOM
AREA=20,317 S.F.SFSAW NAP at ants so* tor PAW
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SURVEY OF PROPERTY
AT GREENPORT
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
1000-33-02-09
SCALE: 1"=30'
AUG. 26, 2002
SEPT. II, 2002 ( certification 1
3P0
9Z-A SUFFOLK COUNTY M DEPARTMENT OP ALIN Spawn !
..'
PERM?FOR APPROVALS?CONSTRUCTIONS*A '
SINGLE,FAMILY REINDENCE ONLY
AT l2 tl-0.2*LS. • . J /c -0/&?
APPROVED _ ' Or Nr''
%,, C3 FOR MAX$MuM OF 44 ' - ' •
G c EXPIRES THREE YEARS PROM DATE OF APPROVAL
tOr r
°' '30 C) .1 EXCAVATION INSPECTION RE QUUIRED o
'f- FOR SANITARY SYSTEM r--+i�
AIP _ BY HEALTH DEPARTMENT I =r-'--tom,
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ECONIC , Ii !'EYORS, P.C.
(631) 765 - 5020 F4X:(631) 765-1797
rietcr
P, 0. BOX 909
r Y r 1230 STREET E
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