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JUDITH T.TERRY .: < Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS �`® ' 1� Southold,New York 11971
MARRIAGE OFFICER Fax(516)765-1823
�_�1� �® � Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER : d 11,01
FREEDOM OF INFORMATION OFFICER /sof
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1341 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : CAROL AND LOUIS WIRTZ
Address 1 : P. O. BOX 631
City St Zip CALVERTON NY 11933
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. #R10-95-0055
Name Of Owner PICACANO, M.
Mailing Address 1
City St Zip 0000
Property Address 1 65 GIN LANE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 88.00 block 4 lot 1 .000
Cross Street MAIN BAYV I EW ROAD
Building Permit Number Cross Reference:
Issue Date: 6/01/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY % t.,.. •
. . Town Hall, 53095 Main Road
TOWN CLERK : ® P.O. Box 1179
V w Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = '®` "V i' Fax (516) 765-1823
MARRIAGE OFFICER _4.2 �• ,0 Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ..
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: May 26, 1995
Transmitted herewith is a copy of application No. 139, for a Cesspool/
Septic Tank Construction Permit submitted by: ,
Carol M. and Louis H. Wirtz for M. Picacano •
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: 7 �- `� ..$2-Th /�/S� ' C/�
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e Agoir. ,
RECEIVED
Signature r
MAY 3 1 1995 �-- � /�
Town Clerk Southold Dated
0.5Z-ICE OF THE TOWN CLERK �
Town of Southold .�' cf1R
Judith T. Terry, Town Clerk ��' O�� � ,.. Application No. / 59
O
Town Hall, 53095 Main Road �� Construction
P. 0. Box 1179rn
Southold, New York 11971 %ct) Alteration
Telephone `'o,�� �o��', $10.00 - Residential
(516) 765-1801 .� '��
� $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 /I/ .
APPLICANT NAME: d / - /J '
J
APPLICANT ADDRESS: Za o� ��, C ,i/Rii
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: /79 2/� �2 G4,/�
r
OWNER MAILING ADDRESS: 6 5�,-'c 2- - it•. _
Sou c-6
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 369
TAX MAP NO. : Section -74294 Block J Lot /
/3(?/)(/0
CROSS STREET : /3 /4;7y
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature o .plicant
RECEIVED BY: AL-f
Town Clerk's Offi'ce-
DATE: /, (7/7
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I am familar with the Standards for }S��� CCS It; (n(Sj. LL A`(:,� o; �,z�L w,t ,
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Approval and Construction of Subsurface �� so LAly0s (.0.�•itfr-A,� r3 LJ LL.
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Sewage Disposal Systems for Single Family :o 41. LEltq G'9` (�>T
Residences and will abide by the conditions .. ' ry0 �'` ROTE �t �,p
set forth therein and on the permit to ti ;� .`; o� '` rlr �d\ Kv
construct. !(c Y�:' ,°. by Dept Oi Health Services
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