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JUDITH T. TERRY . Town Hall, 53095 Main Road
TOWN CLERKP.O. Box 1179
ILP ,,� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ®i✓
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Fax (516) 765-1823
MARRIAGE OFFICER 4* �It Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER '_�®,� '�FREEDOM OF INFORMATION OFFICER ����rii�,r!r�/OFFICE OF THE TOWCLERK
TOWNOF SOUTHOSOUTHOLD WASTEWATER DISPOAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1190 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : WILLIAM S. KELLY
Address 1 : 2325 BRIGANTINE DRIVE
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. #R10-94-0067
Name Of Owner KELLY, WILLIAM S.
Mailing Address 1 SIKORSKI, SANDRA L.
P. O. BOX 1680
City St Zip SOUTHOLD NY 11971
Property Address 1 2325 BRIGANTINE DRIVE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 79.00 block 4 lot 62.000
Cross Street NORTH BAYV I EW ROAD
Building Permit Number Cross Reference:
Issue Date: 8/29/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK t ® P.O. Box 1179
t Southold, New York 11971
REGISTRAR OF VITAL STATISTICS • =
23
MARRIAGE OFFICER �. �"���, Fax ne(5 (516)6) 765-15-1
RECORDS MANAGEMENT OFFICER ®1 °��� �. Telephone 765-1801
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FREEDOM OF INFORMATION OFFICER �.�viiii/''
OFFICE OF THE TOWN CLERK---
TOWN OF SOUTHOLD . D _° 12_a F 2
TO: Southold Town Building Department ( IF'
G231994 :
FROM: Linda J. Cooper, Southold Town Clerk's Office
t
DATED: August 23, 1994 BL®G-®EPT- I
J uvvN OF SOUTI oOLD I
Transmitted herewith is a copy of application No. 1236 for a Cesspool/
Septic Tank Construction Permit submitted by:
William S. Kelly for William Kelly and Sandra Sikorski .
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 recd.. endations:
APPROVE
fir_,/
DISAPPROVE _
Comments: a,/,/1) .,,;.:7.e/ , 6 ....95/— 7
.
1994 Sign, ura/P;/J/c
_
AUS,� �P "--
Town clerk • ou old Dated
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...
OFFICE OF THE TOWN CLERK c\\FFD(, ;'
Town of Southold 0� 0 c2 3
Judith T. Terry, Town Clerk Application No.
Town Hall, 53095 Main Road o { - moi, :" '
Construction
P. O. Box 1 179 cry
Southold, New York 11971 �y, ._ Alteration
Residential
Telephone
(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 $
DATE 521
APPLICANT NAME: L-L , , 6 l/%el
APPLICANT ADDRESS: Z3Z 4 J 1 JL
A/ /l07/
SEPTIC K CESSPOOLN
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
ti •(t) s ,"t, c--LE Filth ( y D eiiv;, �
•
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: 5 . ,6-[_ /-$4AiD1 L, �
OWNER MAILING ADDRESS: C�• �� �6�j
AI IA 7/
OWNER PROPERTY ADDRESS: Z3ZS -fei.:(144-ki-ZAeE
,q 1(�i7 ?
TELEPHONE NUMBER OF CONTACT PERSON: 7t - 4/
TAX MAP NO. : Section /7 9 Block / Lot 6
CROSS STREET: ISO o /� �' A. ."
BUILDING PERMIT NUMBER CROSS REFERENCE:
-.def
010"- Signa 401,1P-4/- Applicant
RECEIVED BY : _ l/v
Tow Clerk's Office
DATE: 0 Z3 �j
WELD q
SUFFOLK CO HEALTH DEPT.APPROVAL _
MAP OF P OPEQTY H.S. NO. ,
hi•
�c==sss CESSPOOLS \ / SURVEYED FOR, - I ,,
` �` PA21C PLAYGROUND QED
�_VACANT &WC _ r \
•
-� I , '�` g,1` t .hra .J -':;\ V 1/_ ✓. :�`:�i N t� ; STATEMENT OF INTENT
1- THE WATER SUPPLY AND SEWAGE DISPOSAL
�6r.L SI.72 _$ 10 E n' J o1 700 0 �� _'`i. SYSTEMS FOR THIS RESIDENCE WILL
_� +, .7"---\: �QQ E -0 y�'1toe�oFla4,t It '-.7,-,CU�'I--!(�{_% CONFORM T. .THE STANDARDS OF THE
S.,' SEPrIc `^'ELLSUFFOLK 'Pi PT. OF 'EA SERVICES.
Es? {�35 \� c'.. �/ / \I- L• arfarw..� �_ APPLICAN ��
(fLES) i\� C3 507 exaul o re ci T \. 2 SENATE •
v :,G SUFFOLK COUNTY DEPT OF ALTH
�,- '60) / I a ,po-,J �� l \ cJ �, SERVICES — FOR APPROVAL FOR
-`.,E_L i -u--- - -i-Tei- I ` " 3 1 } i �� re Me\ I° �PL��! Q CONSTRUCTION ONLY
(cF�s ra s } f _ �9� 411 61 SYar1Ce' DATE 15=-lA�
c %1 p--- - -- - r- - -- ^0Y i NON-TU2FF13 42EA c, d U YJ u '�. `�his -{c ...- supply >�sewage
' 6SHINr r,Cx'r) 0 F '11--_-..
11 ! o 9ELOW LS' COt TOf,¢ > 9e �. H S. REF NO �/D g� A49.6
_ ��t „a > ct► sat fac*t Fes.
> 7 0, f . / = =•r v - APPROVED W.
Ilia
.�' 7 o s ,.....5_;:, t,�
Lit F� I 101
PONa - SUFFOLK CO TAX MAPNATION:
�I AT DIST. SECT BLOCK PCL.
— —
WELL,� n+� ry+�� 1u72 5$ IO W, :`"'� .5 - ,\ ICC�J 079
v 0 '' G'POOLIZEPUTED) ;-t'.5.L''5C v'2E51,N,'.=a;g � ftiET"t.,-;,''
w Sot:u �i2 i A_; C''t_tNtt,'t"t:r= 5 (
OWNERS ADDRESS.
s IA t" ;tt+:�art a 3 94 ;325 SiLiGPN !PIE Df?JVE '
s Ili2-? ; �r ; ., SOl1THOLD N.i Y 1 197i
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.r 1 A�C( fi 2nitwb~��i SF. `1 �d TEL. 105-312 BUS.7,3 O
4 460
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® DEED. L.11/A P.
' J I \ TEST HOLE STAMP
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WELL t HO. 2_12,1994 I ._, - r
oc o- �— tvtAY ZO, 1994
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AMENDED AP `e
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_ C'POOL 0 SEAL
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NOTE:
LOT NGS.IZEFE2TO'MAP OF HA12302 UGI TS-SEC.3. A� 5�_12VEYED NOV.1O 1 3 p •r°
FILED IN TPE 5JEF CC.CLERIC'S OFFICE A5 MAP NO.5!47. — - - ' Z 1 ° '
~-- -- ROD }RICK VAN UYL,R.C.
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LICENSED LAND SURVEYORS �sFocni, ;
GREENPORT NEW YORK �r�x
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