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��� Town Hall, 53095 Main Road
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� r�� Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 646 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : JOAN F. PAVLAT
Address 1 : 1 LIBRARY LANE
City St Zip PLAINVIEW NY 11803
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSYTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 9/19/90.
Name Of Owner PAVLAT, JOAN F.
Mailing Address 1 1 LIBRARY LANE
City St Zip PLAINVIEW NY 11803
Property Address 1 1020 PARK AVENUE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 56.00 block 1 lot 2.017
Cross Street LONG CREEK DRIVE
Building Permit Number Cross Reference:
Issue Date: 10/12/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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1. Town Hall, 53095 Main Road
�_ �%- P.O. Box 1179
�' NO i�, Southold, New York 11971
JUDITH T.TERRY ' ��P31 poo TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF IT SOUTHOLD1 _ �..,,�.'"
To: Southold Town Code Enforcement Officeri1 \\ SEP ;it ,
From: Linda Cooper, Southold Town Clerk's Office ��L___ '� I ��
Dated: September 24, 1990 BLDG. DEFT. �-=�
p TOWN OF SOUTHOLD
Transmitted herewith is a copy of application No. 661 for a Cesspool/
Septic Tank Construction Permit submitted by:
John F. Pavlat .
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 t<
DISAPPROVE
n
Comments: �, Co , 1r
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OFFICE OF THE TOWN CLERK ''''""""'''
Town of Southold o''‘ �Ff
Judith T. Terry, Town Clerk ,,�'��� l/y Application No. ��/
Town Hall, 53095 Main Road Z ` . Construction is'
P. O. Box 1179 ® T � •
Southold, New York 11971 Alteration
Telephone 0 Qi $10.00 - Residential
(516) 765-1801 ��Ol �
$25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ 101 ///////��/
/ DAT -tom/
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APPLICANT NAME: 446_.t‘ / /�,, � ,l/
APPLICANT ADDR'- S: / /41."
SEPTIC CESSPOOL
DESCRIPTION OF PROPOS D CONSTRUCTION O ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUrTION OR ALTERAON: /
OWNER OF PROPERTY: j
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OWNER MAILING ADDRES I :1, / JIM arA_ i
OWNER PROPERTY ADDRESS: ,i0 a
TELEPHONE NUMBER OF CONTACT PERSON: jz -V--99
TAX MAP NO. : Section • 05‘ Block 0 / Lot o?,
CROSS STREET: / I
BUILDING PERMIT NUM:ER ''OSS REFERENCE:
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Signature of Applicant
RECEIVED BY: A .6 _� ,�
i 3 Cc CFO nagcr�s Office
DATE:
SEP S4 ED
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