HomeMy WebLinkAboutKujawski, Daniel TERRY •14,, ofFour
JUDITH T. o Town Hall, 53095 Main Road
%TOWN CLERK P.O.Box 1179
REGISTRAR OF VITAL STATISTICS V O � Southold,New York 11971
MARRIAGE OFFICER .co* 0- i�� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER i .� * -0„.�iTelephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ����•, ,i's.�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1389 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : DANIEL KUJAWSKI
Address 1 : P. O. BOX 290
City St Zip SOUTHOLD NY 11971
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. #R10-95-0097
Name Of Owner KUJAWSKI, DANIEL
Mailing Address 1 P. O. BOX 290
City St Zip SOUTHOLD NY 11971
Property Address 1 THERESA DRIVE
City St Zip MATTITUCK NY 11952
Tax Map No. section 115.00 block 13 lot 15.000
Cross Street RICHARD STREET
Building Permit Number Cross Reference:
Issue Date: 9/18/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
40
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co
II�,il OFF04 ..
JUDITH T.TERRY 1 Town Hall,53095 Main Road
TOWN CLERK t H Z t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS 0 0 Southold,New York 11971
MARRIAGE OFFICER Wi. 0 / Fax(516)765-1823
RECORDS MANAGEMENT OFFICER 0.� `�►�1II' 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: September 14, 1995
Transmitted herewith is a copy of application No. 1441 for a Cesspool/
Septic Tank Construction Permit submitted by:
Daniel Kujawski .
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. jr-------------7" " "_Thank you.
L...............„.,SEPIJ4 19�
4,./K,C6.Q..,
BLDG.DEPT:
Linda J. Cooper AVN OFSOUTHOLD
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE .€
DISAPPROVE /
Comments: -f' ,,Q„„, Sc% i /ay.m91—009-2
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4.7....... .. ire.
Signat
97/(57 ",r
Dated
OFFICE +OF THE TOWN CLERK
Town of Southold 0" IFOtKc"
Judith T. Terry, Town Clerk �' � _ Application No. /yy/
Town Hall, 53095 Main Road ;� ; Construction
P. 0. Box 1179 ; y"o T
Southold, New York 11971 cn / Alteration
Telephone �; $10.00 - Residential
�l r
(516) 765-18010` ��'� $25.00 - Non-Residential
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
i-APPFee $ q q
DATE Sari-
APPLICANT
LICANT NAME: /42
J
APPLICANT ADDRESS:
SEPTIC ,Q CESSPOOL,$
DESCRIPTION OF PRO OSED CONSTRU TION OR ALTERATION S'e42_, c ,e.7
Oma, -
30 S pc9e9
Xes°0122,162
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTI/ONOOR AL RATION:
OWNER OF PROPERTY: 0 iC.�.�,j cx4A S
OWNER MAILING ADDRESS: Po Qa ao o lO
OWNER PROPERTY ADDRESS: _ 'I" vii= .Q
TELEPHONE NUMBER OF CONTACT PERSON: SIC 46S 4/0�6
TAX MAP NO. : Section f S Block, L3 Lot 1 5
CROSS STREET: t'C -wird
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature o/Applicant
RECEIVED BY: ✓)
rk's-'Office
DATE: SEP 14 1995
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LOT 12
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183.10' •
I 0• E .
N. 86.242 r�_.�_-__,'7 '$ / (enc.'
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• (' ` 4' s��,� ,� o SURVEY OF
W o9 S�s><<�, 1 LOT 11
eo 0,8 LOT(i)
- 3 � ��" "DEEP HOLE CREEK ESTATES"
we QN I 1 k, FILED JAN 28,1965 FEE NO. 4256
_?S 3 AT MATTITUCK
Lc \I _ __ '� TOWN OF SOUTHOLD
0
20• I __\ well R
_ -1:, 'T SUFFOLK COUNTY, NY.
i0.3 2o. 2
8C_ �!_ h ictme P O �e1 y1 pipe,
• C N sncd -bldg e 0a fns' lV 1000 - 115���3 - 15
• Sca /e: 1 = 30
o N�, 7„„L• 0 5 ! W July 14, 1993
" h 1� w,ie X86.34'
03 fW inti:-:.--;,...
Y
-- 80•I Tp0" W a; _S;-
SINGLE FA1 ILY WELLU ONLY ��
b aJ
EXPIRES THREE YEARS F LIQ DATE OF APPROVAL � ;�' `�
;.. -
LOT 10
ur),kno w r+ i �` `' Z-'
The locations of wells oqd cesspools
shown hereon are from field observations AREA = 20,021 sq.fL / � �i� •_ , SI.
and or from data obtained from others. 'AA. �� -' oy F
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES �% r-/ = •;_1.. +i+l. m m
FOR APPROVAL OF CONSTRUCTION ONLY The water supply and sewage disposal '.F,a � -+ --
systems /or this residence will conform .;', Y.S. LIC. NO. 496/8
Q 'pp� to the standards of The Suffolk Count Prepared in accordance with the minimum ��;
DATEM6 2 8 925 ��G'j�5���� y standards for title surveys as established /7 �+ 7' *RS, P.C.
REF No. Department of Health Services. by the L.LA.L.S and approved and adopted P � �
4 for such use by The New York Stale Land (5l• 65 - 50-
.1 Title Association. P. O. :*X—•09
i ' P MAIN ROAD
APPROVED 0 ELEVATIONS ARE REFERENCED
TO AN ASSUMED DA TUW. SOUTHOLD, N.Y. 1197/
93 - 234
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