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JUDITH T.TERRY �� Town Hall, 53095 Main Road
TOWN CLERK g t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ` ��, Southold,New York 11971
oFax(516)765-1823
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MARRIAGE OFFICER ` ®Q 11'
RECORDS MANAGEMENT OFFICER ' � � �i �. Telephone(516)765-1800
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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. 1373 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : LUTKOWSKI, A. AND HORTON, D.
Address 1 : SMITH 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. #R10-95-80
Name Of Owner WEXLER, ESTATE OF
Mailing Address 1
City St Zip 0000
Property Address 1 380 PRIVATE ROAD 27
(OFF WATERVIEW DRIVE)
City St Zip SOUTHOLD NY 11971
Tax Map No. section 78.00 block 7 lot 32.002
Cross Street BAYVIEW ROAD
Building Permit Number Cross Reference:
Issue Date: 8/18/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T.TERRY ; Town Hall,53095 Main Road
TOWN CLERK g P.O.Box 1179
P657 t
REGISTRAR OF VITAL STATISTICS VO 00 Southold,New York 11971
MARRIAGE OFFICER ��� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER N.2104 0 `�ij.,ofd Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER „„ ,�•s'
OFFICE OF THE TOWN CLERKf �__
TOWN OF SOUTHOLD
AUG 6 4 ea
TO: Southold Town Building Department
i 4
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: August 11, 1995 ��_TQU,/r` QSOUTHOLDj
Transmitted herewith is a copy of application No. 1424 for a Cesspool/
Septic Tank Construction Permit submitted by:
A. Lutkowski and D. Horton
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: sC ,) gp,x,
Signature /
Dated
•
•
OFFICE OF THE TOWNYr,CLERK . , • '' c:',=•-",1-••••- , _ '` ' • • •,f.. ; ,' , _
Town 'of Southold' -,.:. • - s' ��F�Dck ,,,,,.;,;, ;;-,<,A, '
Judith T. Terry, iTownF=:Clerk' ',%4d$ .,, SOC( ' Qppi_ication ,No.
Town Hall Main„Road •,`- Z - ` ' :x, ,,,Application
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,- 53095 ,;,'° �� "10 '"' ,.0:•'-�;�'�:.,�, ;I^ ;tr- t�°..1�v;y!,_i ; ,
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Southold, New York'.-11971 '- . ;cry. ,_-_,,,,.. .$.1:4,,,•::::::,, '�:L , - '
Telephone ?",-t:,.. ,,`x,',-�' :. `,,x`' 10��f00, =;, esic�ential',
(516) 765-1801,' lr4'. ';• - ;'+ .$25,00 -Non-Residential
F. SOTHOD ,,
: - SOUTHOLD ,WASTEWATER DISPOSAL DISTRICT •
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' - - APPLICATION.- • - ;%:
. , ' for ;
- , ,
. CONSTRUCTION or ALTERATION PERMIT.
' ' - • SEPTIC TANK or CESSPOOL - ` ----•.' '
Permit No• o�aQ1)) ,2. •.
Fee .$ -`'.- ;`
, • DATE .�.;' /n_'w ' t_ ,r: "'
APPLICANT NAME: -•' v�\C�' � pi 'l / ) _.
W� 5 Vim- 1-1':�.:` Iv� �};:,,'. ''� �[.�.�'�
APPLICANT ADDRESS: '-, NAA:.,.-.".r... .''':•\''''.' ,,' . :;\°''.' "'' 'ca.u?-)r , r,,, �i;'-,,I,) - I1
SEPTIC ' CESSPOOL '' , •",:. ,'''';',- i,, . .
DESCRIPTION' OF PROPOSED fbr: •?•ir '.::. r,'
SE CONSTRUCTIO OR 'ALTERATION'
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,^^ STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE D19POSA;
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' • - - SYSTEMS FOR THIS RESIDENCE WILL
\\�\``• �o4 �y Wil. IL CONFORM TO THE STANDARDS OF y� THF
- - �,,0� �S i OC v SUFFOLK CO. DEPT OF HEALTH SERVICES
,``� t ���� ate— —• I ' (5j APPLICANT
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'' ' „iY` ' IW : — — Tr.) HOUSE SUFFOLK COUNTY DEPT. OF
-- - HEALTF
—1-__ — i( ' - - SERVICES — FOR APPROVAL _ FOR
j � '- eU!l CtNCi ijf'i`WE CONSTRUCTION ONLY JULt
E!1VELc7F}Ef,��`' DATE: p UR: 0 6 1
, `{ ` `s0 �' ' H. S- :,E F O. R/4 aQ 4b - ,
C / [ AP- i 1 % •
O,4D _ �/�g Q_ fir' I : - ,, SUFFOLK CO. TAX MAP DESIGNATION:
� / ,F I� j; _i�- - Q— 90 •r-', I I DIST. SECT. i BLOCK PCL.
t`; ,�� fir. i , J s?¢eP. I t,� ° 1=14t;' ::. -� ? '�
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, _ _ _ j No. I c.
I ...01..s' 4e 1 —ji - - 0 -- /8d.-ti I j OWNERS ADDRESS: -
TESt uoi.e• r-- -. — — '
- 1 o '�� WELL 305 SMITH Q /ESOUTH
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O , .,���`' ,� i SCcs"1"NGLR,-N_Y 11971._
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r kip ,iks.. s DEED: L.2341., P.164 I;t3EF.)
0 ( �o/ / �`I ? �' TEST HOLE Una MP
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- Fly T� INSPECTION i� :kx��� �� Ya
I / Pies of this survey map not bearfrag
-� ' {.^ Ly - V ..---- P, ��1 - B{j,j){/,/� the land wrveyor's inked seal or •
-- - Z— - —� — t P. - — - ---- / lay tAAM f to be a va,d true copy embosscd cord shall of beconsidered --
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d �) W o M /r i r , , Guarantees indicated hereon shall run - -
----- V _ -- 1 I- ._ ' -_ _--_-._. __ `• _•_. • ,- - -- —._-----_ _.,_m-i,_- i - _ - ----- -- __ ---- -- -_ ---_- -- __ B9_,OWN only to the person for whom the
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j ('[� •_ l ; - o- - _ P Pared,and on his behalf to the "-
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AMY SAhIR title company,govemmentala
1 _, , agency and
rnstrtutlon listed hereon and
' N 1 ",� 0 COUTO U RS FROM SUFF.CO. O.P.W."AERJ AL to the assignees of the landing fast!
_ I a v G I - PALEargon-Guarantees are not
=; S��i2v,E :{7/�;uM' MEAN =EA 1 VELIttGL O. , 81J transferable,
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< en - to ad:Goo/tat kisututlons orsubseq rat . ,
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