HomeMy WebLinkAboutSwiatocha, Dawn /�,��OSIIFFOL,�c
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ELIZABETH A. NEVILLE e h # ; Town Hall, 53095 Main Road
TOWN CLERK co - ; P. O. Box 1179
�, Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS Fax (631) 765-6145
MARRIAGE OFFICER L O,fi `�-,1��
RECORDS MANAGEMENT OFFICER ei �a� i� Telephone (631) 765 1800
FREEDOM OF INFORMATION OFFICER - ,/���
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2396 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : DAWN GRZEGORCZYK
Address 1 : 655 LESLIE ROAD
City St Zip PECONIC NY 11958
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 #R10-00-0191
Name Of Owner SWIATOCHA, DAWN
Mailing Address 1 655 LESLIE ROAD
City St Zip PECONIC NY 11958
Property Address 1 1485 ORIOLE DRIVE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 55.00 block 6 lot 15.030
Cross Street TUTH I LL ROAD EXT.
Building Permit Number Cross Reference:
Issue Date: 9/13/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
o .
ELIZABETH A. NEVILLE 1 Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
y Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS ‘ V'
MARRIAGE OFFICER :��i. Prr
�1�� Fax (631) 765-6145
4'
RECORDS MANAGEMENT OFFICER � t). Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER I * °°°°���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: August 29, 2000
Transmitted herewith is a copy of application No. 2485 for a Cesspool/
Septic Tank Construction Permit submitted by:
Dawn Grzegorczyk
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 recommendations:
APPROVE
DISAPPROVE
Comments:
Signature •
Dated
OFFIOE OF THE TOWN CLERK �"CO LK
TOWN OF SOUTHOLD %'; CQG- Application Nod S
ELIZABETH A.NEVILLE,TOWN CLERK X
P.O.BOX 1179 lConstruction
SOUTHOLD,NEW YORK 11971 _ •
ocn ^' ; Alteration
Telephone O Ares' $10.00 -Residential
(516) 765-1801 =�l $vo.' $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE A U--0& LW
APPLICANT NAME: OLLAD n
APPLICANT ADDRESS: LOSS
Q�n�L ‘ JL
SEPTIC CESSPOOL
DESCRIPTION OF PROPOS D CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY � n 3L)3\\
OWNER MAILING ADDRESS: C DSS l i s e e •11
OWNER PROPERTY ADDRESS: I yA5 crjd(Q brj,Q)e
TELEPHONE NUMBER OF CONTACT PERSON: ; (o
TAX MAP NO. : Section Block CO Lot
-ND
CROSS STREET:
/ u TTL 2.0,5tBUILDING PERMIT NUMBER CROSS REFERENCE:
,I , ./f
SignaturgInf ppftr:
RECEIVED BY :
"PoWri �rk'5 Office
DATE: v �n 6 U
1111,
s
SURVEY OF LOT 21
MAP OF HI&HPOINT MEADOWS, N
SECTION TWO
FILED MARCH Iq, Iggo, FILE No. IggO
SIIUATE1 SOUTHOLD W y E
TOWN: SOUTHOLD
SUFFOLK COUNTY, NY S
SURVEYED JULY 26,2000 _.....-- .._.�....—..
SUFFOLK COUNTY TAX # pWE\-WINTER I. UFr'C_I:I:UUiV,.UV.PARTM:NT OF HEALTH SERVICES
1000-55-6,-153 )SL\G WA OYAS-LV p%R PERMIT FOR APT'^OVAL OF CONSTRUCTION FOR A
1.. LO'( ,i„,fi80G
22LOT SINGLE FAMILY RE:.ID r CC ONLY
1 CERTIFIED TO: 20 q
�
CHESTER GRZE&ORCZYK til&DAWN GRZEGORGZYK Q0�6f/�Q„� DATE 0-2Z(x�LSi•REF.NO. 10s� O 9.I
CHESTER GRZEGORGZYK ��y�r�f v
et
50'cvIcT 04 ,111 o9 APPROVED a r
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u FOR MAXIMUM OF F0tAr a•ROOM:;
ort ,N, EXPIRES THREE YEARS FROM DATE OF API i2v1AL
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AREA = 22,229 SF OR 0.51 ACRES JOHN C. EHLERS LAND SURVEYOR
6 EAST MAIN STREET N.Y.S.LIC.NO.50202
GRAPHIC, SCALE I"=30' RIVERHEAD,N.Y.11901 REF.\\Hp server\d\PROS\20-219.pro
369-8288 Fax 369-8287