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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERKc=3 T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER ye ti
� �� Fax (516) 765-1823
r�' Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 765 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ALEC POLIWODA
Address 1 : 280 LAUREL AVENUE
City St Zip SOUTHOLD NY 11971
Descripton of Proposed Construction or Alteration
REPLACE EXISTING SEPTIC TANK, FILL OLD TANK.
APPROVED AS SUBMITTED. HOLD 10'0" BETWEEN OLD AND NEW TANKS.
EXCAVATION INSPECTION REQUIRED. CALL 765-1802 FOR AN APPOINTMENT.
Name Of Owner POLIWODA, ALEC
Mailing Address 1 280 LAUREL AVENUE
City St Zip SOUTHOLD NY 11971
Property Address 1 280 LAUREL AVENUE
City St Zip SOUTHOLD NY 11971
Tax Map No. section 56.00 block 3 lot 3.000
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 10/09119 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
tst
F- •:' .;17,7T wn Hall, 53095 Main Road
',- " -9 -� Vic' t P.O. Box 1179
' t . ,4 t�' � Southold, New York 11971
. ,JUDITH T. TERRY 4.041.149 TELEPHONE
TOWN CLERK (516)765-1801
• REGISTRAR OF VITAL STATISTICS OFFICE OF9THE TOWN CLERK 1
TOWN OF SOUTHOLD I t ,
October 1l 1991 i
, { r�
To:- Southold Town Code Enforcement Officer ;;iv; ,: -'. "' <w '
• From: Linda J. Cooper, Southold Town Clerk's Office
Transmitted herewith is a copy of application No. A787 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Alec Poliwoda .
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.
w
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
• •- above and make the following recommendation:
• APPROVE - X
DISAPPROVE -
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Signature s' D
Date
O 9 l 9 OCT 09 19Q1
Town ClerR Southold
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• d Town Hall, 53095 Main Road
. - '•,- .` • ,; P.O. Box 1179
? Southold, New York 11971
,JUDITH T. TERRY TELEPHONE
TOWt* CLERK (516)765-1801
• REGISTRAR OF VITAL STATISTICS OFFICE OFVFHE TOWN CLERK
TOWN OF SOUTHOLD
• • October 4, 1991
To:- Southold Town Code Enforcement 'Officer
• From: Linda J. Cooper, Southold Town Clerk's Office
Transmitted herewith is a copy of application No. A787 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Alec Poliwoda
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
•
* * * * * * * =
have reviewed the application and location map of the project listed
• - above and make the following recommendation:
• APPROVE -
DISAPPROVE -
COMMENTS:
•
Signature
Date
OFFICE" OF THE TOWN CLERK � ,,'",,,"''%
Town of Southold ."'� C,� fW Wire-
- p
Town Clerk o c Application No. 70 7
Judith T. Terry, y
Town Hall, 53095 Main Road �� �O f Construction
P. O. Box 1179 v rn
Southold, New York 11971y Alteration
Telephone �� ! $10.00 - Residential
(516) 765-1801 IWO/ 44 NW,/ $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
APPLICANT NAME: /L E p FOL / W O D 4
APPLICANT ADDRESS: go L I (J i-? f L - V r
// 9 -21
SEPTIC [/ CESSPOOL
DESCRIPTION OF PROPOSED ��TION OR ALTERATION •
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: -S---/yi
OWNER MAILING ADDRESS: S /9 rvi F
OWNER PROPERTY ADDRESS: S,� , i E
TELEPHONE NUMBER OF CONTACT PERSON: °1 - / 3 2,4
TAX MAP NO. : Section Block 3 Lot 3
CROSS STREET: `M a J d
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY: ,gd, , n�
TownClerk' Office
DATE: _ 0 .
OCT 041991
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