HomeMy WebLinkAboutPolacek a�11=1 Fri
I Town Hall, 53095 Main Road
°Y® 4*.r. 0° P.O. Box 1179
'y®1 °l!`a�,i' Southold, New York 11971
JUDITH T.TERRY FAX/0-
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. 659 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : CLIFFORD D. POLACEK
Address 1 : 2905 WESTPHALIA ROAD
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
CONSTRUCT NEW CESSPOOL DUE TO CONSTRUCTION OF GARAGE. APPROVED FOR A
REVISED PLAN. PLEASE SEE ATTACHED.
NOTE: EXCAVATION INSPECTION REQUIRED. CALL 765-1802 FOR AN APPOINT-
MENT.
Name Of Owner POLACEK, CLIFFORD D.
Mailing Address 1 2905 WESTPHALIA ROAD
City St Zip MATTITUCK NY 11952
Property Address 1 2905 WESTPHALIA ROAD
City St Zip MATTITUCK NY 11952
Tax Map No. section 114.00 block 10 lot 1 .000
Cross Street DEER DRIVE
Building Permit Number Cross Reference:
Issue Date: 10/31/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OCT6 s
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JUDITH T. TERRY 4".....,00 eiri TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
October 25, 1990
To: Southold Town Code Enforcement 'Officer
From: Linda J. Cooper, Southold Town Clerk's Office
Transmitted herewith is a copy of application No. A674 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Clifford D. Polacek .
Please review the application and location map and advise if this office may
issue the permit.
Please complete the form below and return it to this office.
Thank you.
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE -
DISAPPROVE -
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NOTE:
a =MONUMENT.
SUED/V/S/ON MAP FLED /N THE OFF/CE
OF THE CLERK OF SUFFOLK COUNTY ON
AX MAP .
r JULY 25,/960 AS F/LE NO.3204.
BLK 10 LOT 1
N THUS: (IS.I) ARE
3.V.D (MSL 1929).
•
•
IREVISIONS I YOUNG & YOUNG
OFFICE OF THE TOWN CLERK ,.,'"'"
Town of Southold ���' � �FFoc�( . `7
Town Clerk %` �� ��l/ . Application No. �
Judith T. Terry, � y��
Town Hall, 53095 Main Road ; Construction
P. O. Box 1179 ; o rn ; �/
Southold, New York 11971 Alteration
Tele hone bQ��i� $10.00 - Residential
7 l
(516) 65-1801
��,, ��o
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
/O -ZL4O
DATE
APPLICANT NAME: Clt f 1✓• e / 1L
APPLICANT ADDRESS: 2. L 0 t4.12..1-7;4401, 12.a�
ina. ttt. ck , Nv H9J-2
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
C 0 AI ST ri& cl Gat ra.7 -
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
A 61a.tOWNER OF PROPERTY: C I c FFdrJQ ✓�• e �C
OWNER MAILING ADDRESS: i2 ?O Cil/ P s 7-'44 f1& -
Mgi1'7;rkc Ic , ivy /19 2.
OWNER PROPERTY ADDRESS: SCc •tet e
TELEPHONE NUMBER OF CONTACT PERSON(7A7-3,ro5 Ditty ..9 F.- Irv(r
TAX MAP NO. : Section / /91 Block t U Lot
CROSS STREET: 17 de St A.
BUILDING PERMIT NUMBER CROSS REFERENCE:
t�•
Signa e of Applicant
RECEIVED BY: _,
Town Clerk's Office
DATE: / nzis/c
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. NOTE: _
® =MONUMENT
SUBDIVISION MAP FILED MI THE OFF/CE
NOTE: • OF THE CLERK OF SUFFOLK COUNTY ON ` •
I. SUFFOLK COUNTY TAX MAP JULY 25,/960 AS F/LE NO.3204.
DIST. 1000 SECT. 114 BLK 10 LOT 1
2 ELEVATIONS SHOWN THUS: (1-5.1) ARE
REFERENCED TO N.G.V.D (MSL 1929).
I
REVISIONS YOUNG YOUNG
OCT. 22, 1990 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK
•
ALDEN W. YOUNG HOWARD W.YOUNG
- - PROFESSIONAL ENGINEER AND LAND SURVEYOR
LAND SURVEYOR. N.Y.S. LIC, NO, 12845 N.Y.S LIC. NO. 45893
SURVEY FOR: -
UNAUTHORIZED ALTERATION OR ADDITION TO _
THIS'SURVEY IS A VIOLATION OF SECTION CLIFF POL A C TI( - OF C
7209 OF THE NEW YORK STATE EDUCATION �•(� SC�r
LAW LO T -NO. /9 , „DEER P,r'i o. ►� A®
COPIES OF+THIS SURVEY MAP NOT BEARING -a�� y0
THE LAND SURVEYORS INKED SEAL OR 0 • 0
EMBOSSED SEAL SHALL NOT BE CONSIDERED ///JJ
TO BE A VALID TRUE COPY - AT -y, N .iu --. /
MA T T/ TUCK
,.
GUARANTEES INBICATED HEREON SHALL RUN
• SNLY TO THE PERSON FOR WHOM THE TOWN OF
J�rr C+��T��L�
SURVEY IS PREPARED,AND ON HIS BEHALF SJ �f
TO THE TITLE COMPANY, 30VEPNMEN AL O '
% AGENCY AND LENDING INSTITUTION LISTED J
• HEREON,AND'TO THE ASSIGNEES OF THE _ _ SUFFOLK CO,, N.Y. - ,.. .J/�j,,l� � /
LENDING INSTITUTION GUARANTEES ARE ( �'/ � ��. -
• NOT TRANSFERABLE' TO ADDITIONAL - SCALE: it '--"''S. DATE• p�AR. 't'':, ` •
-, •
INSTITUTIONS OR SUBSEQUENT DOWNERS•, ti - - , •� = 40 MAR, 2T, 1990 - - 90-0188 .
,