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•
JUDITH T.TERRY © Town Hall, 53095 Main Road
•TOWN CLERK gg, P.O.Box 1179
•
REGISTRAR OF VITAL STATISTICS •� O v 1� Southold,New York 11971
MARRIAGE OFFICER ��j '� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER .q ED 'Vosiii Telephone(516)765-1800
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. 1300 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : JOHN BERTANI BUILDER
Address 1 : 1380 OAKWOOD DRIVE
City St Zip SOUTHOLD NY 11971
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. #R10-95-0015
Name Of Owner SUROZENSKI, JEROME & VIRGINIA
Mailing Address 1 P. O. BOX 92
City St Zip CUTCHOGUE NY 11935
Property Address 1 CROWN LAND LANE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 102.00 block 7 lot 3.000
Cross Street SPUR ROAD
Building Permit Number Cross Reference:
Issue Date: 3/23/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/c; e`
JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERKP.O. Box 1179
� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
Fax (516) 765-1823
MARRIAGE OFFICER ® ��® Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER ��
OFFICE OF THE TOWN CLERK 1 J J J J s
TOWN OF SOUTHOLD
MAR 1 6 1995
TO: Southold Town Building Department �C,L;.Ian��_PT.=� `'
r g.
FROM: Linda J. Cooper, Southold Town Clerk's Office TONOFSOUTI-101=P'=—'"
DATED: March 16, 1995
Transmitted herewith is a copy of application No. 1347 for a Cesspool/
Septic Tank Construction Permit submitted by:
John Bertani Builder for Jerome & Virginia Surozenski
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 �r
DISAPPROVE
Comments: mere c /l /(2—� e045—
Signature
/ //c<5-
Dated
OFFICE OF THE TOWN CLERK ,,,,"""
r Town of Southold ��•'�O��FfOL1(00- Application No. ��
Judith T. Terry, Town Clerk �� [i
Town Hall, 53095 Main Road Z .G .
Construction
P. 0. Box 1179 • r:
v '-^ • Alteration
•
Southold, New York 11971 ‘ct� - �.•
Telephone ;� y�Y �Q��•' $10.00 - Residential
(516) 765-1801 -_ �l �, , $25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ /C', tl�
DATE -3/(5-/f5--
APPLICANT NAME: J664t, . e6e779‘A/ eve 24.967e_
APPLICANT ADDRESS: (3 (9.0, 0,44,0-6,9 >e/i.
3 v �1,,o-U) ( (97/
SEPTIC 'CESSPOOL ,I/•
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
-i:Po 27 c K trvon¢ w
LOCATION MAP: . Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Je,zoytE / j,0"4' --C70)20
OWNER MAILING ADDRESS: go , i c4 P�
eiu1/-6 6'Oc 7(93/ /0
OWNER PROPERTY ADDRESS: 64553",4-/ /,6-a,(O
TELEPHONE NUMBER OF CONTACT PERSON: ,pc,----/J— cz
TAX MAP NO. : Section /0 Block 7 Lot
CROSS STREET: SPc..Jf2_ R.-64-{)
BUILDING PERMIT NUMBER CROSS REFERENCE:
eYe-C4 1 4
Signature of Applicant
RECEIVED BY: ALI /
Town Crk's Office
DATE: j/// ./2
•
— SUFFOLK CO.HEALTH DEPT APPROVAL •�
MAP OF P1?QPE1< 1 Y H S NO. •
-- SU` ,VE`,IED- FOP_ MOLE FAMILY DIMELLPIi( ONL; '
jiEXPji:.:- r,, \A F vii-2(- 1 1\ { J
IRES THREE YEARS FROM DATE OF APPROVAL
r `� r".'Ir
HOUSE) ' ;,
�C)0 * N '1/ STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE DISPOSAL
SO' ----ji / A7 SYSTEMS FOR THIS RESIDENCE WILL
//‘'
� CUTCE IOGUE CONFORM,.(fQS,TAHE i35T luf2�R�PS OF THE
�� SUFFOLK(C -rlJaDwE F HEALTH SERVICES.
{ CO Tc\P/N QF OU t HQ ✓ f_•1:Y/ (S) �� U"a7F HE /'� •
1 APP ICANT
i3 ----- lo��(r-u Rd• �T140v's a 1151 )L-1--133-1.-
I SUFFOLK COUNTY EPT OF HEALTH
SPU(t I�O�� r SERVICES - FOR APPROVAL OF
\ //\ CONSTRUCTION ONLY
'\ N.42 33 50�E. 179.1 1 - DATE: ( c�.
` H.S.REF NO.. C7 - l -D D
A } O - ' / i-i V-1-5° T' ,/'/ AP' '.0,.. i Allir
' O .( i
I 1
o // SUFFOLK CO TAX MAP DE'-GNATIO
V o - U:- f) DIST. SECT BLOCK PCL
/ 9_ t' / (000 102 7 3 •
/ 1 (R in ' / OWNERS ADDRESS.
0 Pf2OP WELL ' 1
P O.>px 92
9.
< (7.3CIALL- 30, I
S Q o ro. 11o / A,` CA_I�1,7 �i`- i_ (734-(o71 I)
�1� I I c ;_-;= MUNUMEF\;T DEED L. '4/A P
S33( 3S Hi1d3N VA�f JK T.i 11 ----• ---
AO '1,331 'a S I j , C' 12C F'l r'� TEST HOLE STAMP
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P661 67. 330 S A,— P20P-SEPrtc' - 1= CESSPOOL ,-
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LICENSED LAND SURVEYORS
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