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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWNall, 5•
P.O. Box 1179
tfs Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �! Fax (516) 765-1823
MARRIAGE OFFICER �RECORDS MANAGEMENT OFFICERiv
Telephone (516) 765 1801
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1167 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : JOSEPH W. PETRAUSKAS
Address 1 : P. O. BOX 295
City St Zip MATTITUCK NY 11952
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. #R10-94-0058
Name Of Owner PETRAUSKAS, JOSEPH W.
Mailing Address 1 P. O. BOX 295
City St Zip MATTITUCK NY 11952
Property Address 1 1250 SOUTH HARBOR ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 75.00 block 7 lot 1 .003
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 7/20/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I Wire;
410
JUDITH T. TERRY % Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Cl9 � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = W'® Fax (516) 765-1823
MARRIAGE OFFICER ___ej'�® Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER ��/i�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD /Lig
fill 8 199
4
TO: Southold Town Building Department 1 TOWN®SOEPr Lig/
FROM: Linda J. Cooper, Southold Town Clerk's Office uryOLD
DATED: July 7, 1994
Transmitted herewith is a copy of application No. 1211 for a Cesspool/
Septic Tank Construction Permit submitted by:
Joseph W. Petrauskas
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.
41("°(''`L
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE l�
DISAPPROVE
Comments: SZ / ', 0 9 4- ® 0 s
L
RECEIVED)
Signatur=
JUL 2 0 1994 716
Dated
Town Clerk Soulhe[l
OFFICE `aF THE TOWN CLERK �,,,,"""
Town of Southold �.,'" \\FFDIx
�'J .- ��y o.
' ApplicationN
Judith T. Terry, Town Clerk �E. :>_ > ` l/
Town Hall, 53095 Main Road � ;,. . G Construction
P. O. Box 1179
v • - rn Alteration
Southold, New York_ 11971 , t.t'I
TelephoneQ °�'� $10.00 - Residential
(516) 765-1801 1 �� �
$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 7 / 7/7Y
APPLICANT NAME: 7-0,5 - 1,t,) Prex (A J c(5
APPLICANT ADDRESS: pc) g o ar a-9.5
ex c ivy 1I9Sz
SEPTIC i/ CESSPOOL ✓
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
Cor,,s-F. o / 'j Fam i I� ,n w e
LOCATION MAP: ' Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION :
OWNER OF PROPERTY: _ L_S s -p i �, Pe4ira u-s JCcc_5
OWNER MAILING ADDRESS: P ol< o�9S-
1n_a f-/- (`-- uLc_K N l
OWNER PROPERTY ADDRESS: .�� /
A,S14-6 r ho.r- a(. so Lc-f-ho J f7 Al /f?7/
' TELEPHONE NUMBER OF CONTACT PERSON: 2 - S/D 9
TAX MAP NO. : Section 0 7 5 Block 7 Lot /., 3
CROSS STREET: pito [y, g0
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY: -/
4-4.--"frce
Town Clerk's Office
DATE: �/7//9 . •
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• I. SUFF11 . OLK CO.HEALTH DEPT.APPROV
8.1 ti.S. NO. J
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WELLS f `� I -
suRQZE SV ' i �,
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(VAC.) /
y 4S / STATEMENT OF INTENT
!fjI L THE WATER SUPPLY AND SEWAGE DISPOSAL
QQ SYSTEMS FOR- THIS RESIDENCE WILL
r4.76°37 30 E. r. •
+ l�ii CONFORM TO THE STANDARDS OF THE
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EXPYJ. Y _ (Si
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�eC SERVICES - FOR APPROVAL FOR
'— —. I CONSTRUCTION ONLY
I '- --I L HCUSE ,` G '', , CI I DATE: JUN 2 71994
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r' Q i i 1 H.S.REF.NO.: R\ -C
•_1 L I • APPROVED: I I,
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..-_, , • o ri SUFFOLK CO.TAX MAP •
— T�i 1 1 GNATION:
• `- i-----1 --t- ;lyc y ;; DIST. SECT. BLOCK PCL.
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t`� 132O / OWNERS ADDRESS:
411u1 III ' P,O.BOX 295
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