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'�' � Town Hall, 53095 Main Road
OiM P.O. Box 1179
� Southold, New York 11971
JUDITH T.TERRY FAX/ 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. 590 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : SIMICICH, CATHERINE
Address 1 : 4250 BERGEN AVENUE
City St Zip MATTITUCK NY 11952
Descripton of Proposed Construction or Alteration
NEW SINGLE FAMILY DWELLING WITH CESSPOOL SYSTEM.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES ON 3/8/90.
Name Of Owner WAS, NETTIE AND FRANK
Mailing Address 1 C/O CATHERINE SIMICICH
4250 BERGEN AVENUE
City St Zip MATTITUCK NY 11952
Property Address 1 CAMP MINEOLA ROAD
City St Zip MATTITUCK NY 11952
Tax Map No. section 122.00 block 5 lot 3.002
Cross Street KRAUS ROAD
Building Permit Number Cross Reference:
Issue Date: 3/28/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
l�: 101, 4,
`.�.. j 17/14;
th LP We ;TF t Town Hall, 53095 Main Road
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< (�--•1 P.O. Box 1179
(f� �-� ��� Southold, New York 11971
JUDITH T.TERRY „, 01ioTELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
_ TOWN OF SOUTHOLD
•
To: Southold Town Code Enforcement Officer
From: Linda Cooper, Southold Town Clerk's Office
Dated: 'March 13, 1990
Transmitted herewith is a copy of application No. 605 for a Cesspool/
Septic Tank Construction Permit submitted by:
Catherine `Simicich for Nettie and Frank Was
Please review the application and location map and advise if the project
has received Suffolk County Heall Department approval and if this office
may issue the permit. 1 1.4aiwo
Please complete the form below and returnrsitW-gel:)f
V• tri t 'a
Thank you. 1 1 I. � 3,i- ° � 1
i F',r f
-,,,,,,,_,4?
Linda J J. Coo
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE tC •
DISAPPROVE
(
• '
Comments: Q,o N.,, ae«
• ZcA-noS Coca. 44.e �.��, 3\$ d
. \C-1 ,1, Oact-‘11--,
Signature
rAz—"Oct b .
Dated
,
OFFICE OF THE TOWN CLERK ' ' (‘S\VFU(k D
Town of Southold ��• '' C
Judith T. Terry, Town -Cleric' ° Application No:-605
Town Hall, 53095 Main Road o •'w- Construction v
P. O. Box 1179 Er) s.
O ' $ Alteration
�
Southold, New York 11971
Residential r/
Telephone! i
(516) 765-1801
Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee •$ /0
DATE ' / / /3 /99 O
,
APPLICANT NAME: 4
APPLICANT ADDRESS: 1„,7 S6 !r/i
SEPTIC 1------CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
j •
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: � � /
OWNER OF PROPERTY: g= e /Ce/ �_% J'
OWNER MAILING ADDRESS: G'
//9 S
• OWNER PROPERTY ADDRESS:
, Altir /'Vysc7
TELEPHONE NUMBER OF CONTACT PERSON: 0g9a. -516
TAX MAP NO. : Section /tea Block Lot
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
(_,/201, / /,
Signature of pplicant
RECEIVED BY: /-c_C.�0-
Town iClerk's Office
,DATE: /ys-D
�" r •� I - - • - -
STATEMENT OF INTENT " ! ' A'
i 1,, r 1-11�t 1 ' I
THE WATER SUPPLY AND SEWAGE DISPOSAL ' I . ---• --------- \ I * r
SYSTEMS FOR THIS RESIDENCE. WILL f, !••'•_
• CONFORM TO THE STANDARDS OF THE I" I\'
SUFFOLIX)CO DEPT. OF HEALTH SERVICES, ; '11'• t -`� ' .- ___ f Pr. ��
(S) (Vi.CMN T ) ;
APPLICANT °- i` f I:-- - - - - y ___ --IT:— It S.
j•rit�r�.r ^ ica�:n0
SUFFOLK COUNTY DEPT, OF HEALTH 'f'ir;� a' , \,t'�'C/.\!/\�. 'NItN�C)L!1 f=.L�/\17` y r 0 It
SERVICES — FOR APPROVAL OF (, ; " y ^ __ •• 5.7'07'00" \V. — I50.0 _ � _ � �
r�Q R fit- b
CONSTg4tTV O �y�U Y • - 418345.46
p/lot-1i. • ' t O ��i N
DATE: \. _ tr,V�r4u� t I u
H. S. REF. NO.: q • „,.....e (" .; i i > ,� ` I-._i
APPROVED: .��i>t�_ ..l p( ; to t,Q ,a 1N �' {N ,I
lR (07 3 469$'-- , '�,' / A
tti
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5UFFOLK•CO. TAX MAP DESIGNATION: , T I iii `\
, 4 3 til
.DIST. SECT. BLOCK PCL: 't' % I 'os, • (n 11��'
,�a '000 ` t----- --- S. _. •.34 2 �i . g'• ^O ' `� ,_ , moi,.. k �_j e ' - a 41-2 _
OWNERS ADDRESS: • ,,; -� r (� C ` �
5�o CATNE2INE Sl M!CICN. ;' r i �'/ c\ �a` ___ !" �`
' "....r 4250 BE2GEN•AVE, . , ' ', if,; s, '
.MATT1TUCIG, N•Y. I1952 - •. _-1 U - + a-1 �g - `�
c 1,. U I t r.i- r- � I
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DEED: L.7500 , P. 257 (12E6 • • i N v d- �� �'
TEST HOLE STAMP . T W
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