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04
JUDITH T. TERRY •< . Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS ‘":"-VA,
�� Southold, New York 11971
MARRIAGE OFFICER V �' Fax (516) 765-1823
411 I%�,`jl % 0 •.° Telephone Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1101 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : JOSEPH & SUZANNE ANDREJACK
Address 1 : 381 MARCY AVENUE
City St Zip RIVERHEAD NY 11901
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. SCHD REF. #93-S0-77
Name Of Owner ANDREJACK, JOSEPH AND SUZANNE
Mailing Address 1 381 MARCY AVENUE
City St Zip RIVERHEAD NY 11901
Property Address 1 1305 LIGHTHOUSE ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 50.00 block 6 lot 5.009
Cross Street SOUNDVIEW AVENUE
Building Permit Number Cross Reference:
Issue Date: 4/04/94 Judith T. Terry
Southold Town Clerk
I TOWN SFAI
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JUDITH T. TERRY %,, • *.G ; Town Hall, 53095 Main Road
TOWN CLERK : p T P.O. Box 1179
tli �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ‘‘`04,4b. �. ',' Fax (516) 765-1823
MARRIAGE OFFICER _'`^ ��O 6i Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER _ 1 .�
FREEDOM OF INFORMATION OFFICER =�.,...,,,Iiiiii,�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department 7
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: March 4, 1994
Transmitted herewith is a copy of application No. 1137 for a Cesspool/
Septic Tank Construction Permit submitted by:
Joseph T. and Suzanne Andrejack .
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.
/ -/ ce cc
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following_ recommendations-
APPROVE v
DISAPPROVE
Comments: c SC, 2______eye/ 9 3 _ 5o ,, 7 7
WIMP
1 1994
Covin CI" Signatur
(_ 9 011
Dated /
e.
OFFICE OF THE TOWN CLERKFOLA
Town of Southold cV,_; C�
Judith T. Terry, Town Clerk �;•'•` '
�' Application No. )fi
Town Hall, 53095 Main Road ov7 t� 1.'"�'% � Construction
� "'''—t-r]
P. O. Box 1179
� ..t� •-
Southold, New York 11971 Alteration
Telephone "0l xi s�� Residential
(516) 765-1801
��`'
Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
•
Fee .$ /a. a d
DATE March 4th, 1994
APPLICANT NAME: Joseph T. and Suzanne Andrejack
APPLICANT ADDRESS: 381 Marcy Avenue
Riverhead, NY 11901
SEPTIC CESSPOOL -
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
nnc-family residential dwelling
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Joseph T. and Suzanne Andrejack
OWNER MAILING ADDRESS: 381 Marcy Avenue
-rhead, New York 11901
OWNER PROPERTY ADDRESS:
---1-3 9 . gh t r auae R o a d
• thold, New York 11971
TELEPHONE NUMBER OF CONTACT PERSON:
77_7114 ( Sue Andrejack)
TAX MAP NO. : Section 50 Block 6
CROSS STREET: L
BUILDING PERMIT NUMBER CROSS •
REFERENCE:_.
•
Signature of ,'pplicant
RECEIVED BY: t
Town Clerk's Office
DATE:
i I SUFFOLK CO. HEALTH DEPT.APPROVAL , 1
, Jlz j H.S. NO.
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�n r VACAt IT � ("� ' , �� I :'�/E t Ir W C ''
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/ ~ _`s, EL" L. ^ STATEMENT OF INTENT
I / m, I .u,i, in I
. t. 4E E,� 'i,�E. - %E?, , , i ` Z / I THE WATER SUPPLY AND SEWAGE DISPOSAL
i r 1 1 3\ SYSTEMS FOR THIS RESIDENCE WILL
6 - n, U V / CONFORM TO THE STANDARDS OF THE
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_ - _ -_- L--_—. --- -- 1 ` I t I , SUFFOLK0 DEPT. OF,HEALTHHSSERVICES.
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`� I c��,� I _ \ SUFFOLK COUNTY DEPT. OF HEALTH I
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/ 1r l_r. �� / SERVICES - FOR APPROVAL FOR
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C F t� c H.S.REF. NO 7356 '72
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✓'Jam. CL‘:' -I W DIST. SECT. BLOCK PCL. _
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`\\^`\!14,.���� to this survey is a viota"ee of
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Section 7208dCre Now York SIM
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EXPIRES THREE YEAf5 FROM OAT OR APPROVAL ---_ ---
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DATUM t MEAN SE.A L�'_ '_.
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