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Home My WebLink AboutKowalski, Johnj ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR, OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT CONSTRUCTION OR ALTERATION PERMIT SEPTIC TANK or CESSPOOL Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (516) 765-6145 Telephone (516) 765-1800 Permit No. 2095 R Residential X Non -Residential Fee $ 10.00 Septic X Cesspool PERMIT ISSUED TO: Name : LINDA KOWALSKI Address 1: 930 OLE JULE LANE City St Zip MATTITUCK NY 11952 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 #1110-99-0008 Name Of Owner KOWALSKI, JOHN 8 LINDA -------------------- --------- Mailing Address 1 930 OLE JULE LANE ------------------------------ ------------------------------ City St Zip MATTITUCK NY 11952 -------------------- -- ---------- Property Address 1 700 OLE JULE LANE ------------------------------ ------------------------------ City St Zip MATTITUCK NY 11952 -------------------- ------------ Tax Map No. section 114.00 block 12 lot 13.006 Cross Street NEW SUFFOLK AVENUE ------------------------------ Building Permit Number Cross Reference: Issue Date: 6/18/99 ---------------------------------- Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER 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: June 11, 1999 Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 � � S Transmitted herewith is a copy of application No. 2183 for a Cesspool/ Septic Tank Construction Permit submitted by: Linda Kowalski 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: ignatu c.�►� 45 Dated o- N0 s ti-" OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TO: Southold Town Building Department FROM: Linda J. Cooper, Southold Town Clerk's Office DATED: June 11, 1999 Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 � � S Transmitted herewith is a copy of application No. 2183 for a Cesspool/ Septic Tank Construction Permit submitted by: Linda Kowalski 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: ignatu c.�►� 45 Dated E OFFICE OF THE TOWN CLERK TOWN OF soU rHOLD ELIZABETH A. NEVILLE, TOWN CLERK P.O. BOX 1179 SOUTHOLD, NEW YORK 11971 Telephone (516) 765-1801 TOWN OF SOUTHOLD Application No. Construction Alteration $10.00 - Residential $25.00 -Non-Residential SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT Permit No. Fee $ (o, 00 APPLICANT NAME: APPLICANT ADDRESS: SEPTIC TANK or CESSPOOL 1 DATE une. �l / 9q / SEPTIC CESSPOOL_ DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: OWNER OF PROPERTY: t- -0-040 /I hu1CL 5•�� OWNER MAILING ADDRESS: �.30 0.44" vK�P A -T7 -i �i� LK /✓� �� ,S-� OWNER PROPERTY ADDRESS:_7,0,0 Dx' �Tu�G .CaJ TELEPHONE NUMBER OF CONTACT PERSON: o2i�%S'96� �� 76s'/��9� TAX MAP NO.: Section �/� Block / Lot /- CROSS STREET: BUILDING PERMIT NUMBER CROSS REFERENCE: Signature of Applicant RECEIVED BY: T /,, / ow Clerk's Office DATE: `� SGC C- �f \ SWFO" CO: WMAN =FOLK cwmv t3EPA6tnaetff OF V�, FOR APImvA! OFC "iiON OF ,MLE FA1,4,LY DEVICE ONLY W. o 9 q o s JE tic ,mov D v,-. ; APPROVAL �TATEhIENT OF INTENT_ THE WATER'SUPPLY AND SEWAGE DISPOSAL r]M7'e,nc'leu Ps: 99`g RODERIGK.VAN T�U+YL.�. a. 1 �... ti LICENSED LAND "ViYpRS GRER111PORT NEW YORK DIST, SECT BLOCK PCL. OWNERS ADDRESS 1; 57Zi i i LDEED: L. %C ?'I~ P. 7949 �B SYSTEMS FOR THIS RESIDENCE WILL I CONFORM TO THE STANDARDS OF THE SUFFOLK CO. DEPT. OF HEALTH SERVICES. j (S) I APPLICANT I SUFFOLK COUNTY DEPT. OF HEALTH SERVICES - FOR APPROVAL FOR o CONSTRUCTION ONLY DATE: A H. S. REF. NO.: ±i APPROVED: SUFFOLK CO. TAX MAP DESIGNATION: r]M7'e,nc'leu Ps: 99`g RODERIGK.VAN T�U+YL.�. a. 1 �... ti LICENSED LAND "ViYpRS GRER111PORT NEW YORK DIST, SECT BLOCK PCL. OWNERS ADDRESS 1; 57Zi i i LDEED: L. %C ?'I~ P. 7949 �B SUI--I-*OLK COUNTY DL'•PAICI-MLNT Ot: HVIAI:114 SERVICL•s ` OFFICE OF WASTEWATER MANAGEMENT SUFFOLK COUNTY CENTER RIVERHEAD, NEW YORK 11901 (51 G) 852-2100 APPLICATION FOR EXTENSION, RENEWI�r OR TRANSFER OF EXISTING PERMIT TO CONSTRUCT SE..AGI DISPOSAL AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING Before completing this application refer to "Instructions to�tencw. Extend or Imnsfcr an Existing Permit ft: r Single Family Residence" on reverse side of tllisV li&&n 8 h r1 -7 1. EXISTING REFERENCE NUMBER (If number is prefixed with 93-, 92-, 91-, etc., Wnew application form [WWM-059] is also required) 2. TAX MAP NUMBER: District 1000— Scction Block — 1 �— Lot 3. NAME OF APPLICANT -L JAI (If name is different from original apaiicant, see instructions for. transferring a permit and complete section 6 aelow. z PHONE ADDRESS �.30 O � C `1 u �. � �� M � ZCi S�f�7�11—�--�' 4. NAME NAME OF AGENT (If not applicant) none, ADDRESS PHONE 5. DATE OF ORIGINAL APPROVAL 3 _ q _ 4 S (If mole t1mn 6 years old, a new application will be mr riled.) 6. TRANSFER OF PERMIT: I hereby transfer all rights and interest in the above referenced penr.;it to die nc applicant named above, SIGNATURE OF ORIGINAL PERMIT HOLDEWAGE NT PRINT NAME DATE ADDRESS PHONE . . Application is hereby made to [ ]extend, [ ]renciv, ( ]transfer a permit to construct a water suppl; , and sewage disposal system for a single family. residence in accordance with the application, surveys and plans submil.'ed. I hereby certify that I have examined the complete application and the statements therein are true and correct, and that all work shall be done in accordance with all applicable Town, County, State and Federal Laws and Codes. "Any false statement .Wade herein is punishable as a misdemeanor pursuant to S210.45 of New York State Penal Law." SIGNATURE OF APPLICANT/AG� DATE PRINT NAME .0 i il4nA K oj 4 L- S TITLE _vj, "A._. f you are making substantia] revisions or modifications to a:pinject that has already received a permit to cr, nstruct :from he Department, or if the permit is more than six (6) years old, a new application will be required. Follow th,.; instructions is explained in `Submission'Requirements For Single Family Residences' (WWM-041). Renewed permi- s are subject o any changes in standards enacted after the approval date of the original permit. Permit is •Ext:udedyRcnewed Until Signature of Department Representative WWM-104 (rev.,11/97) FIV rr 4BooApprov r 1-7 q9 �M �� _-X_____---~ .m