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JUDITH T.TERRY % fe Town Hall, 53095 Main Road
TOWN CLERK g P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ; � Southold,New York 11971
MARRIAGE OFFICERr
e Fax(516)765-1823
RECORDS MANAGEMENT OFFICER ®4 ��®filFax
(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. 1199 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : CLAY PIT PROPERTIES INC.
Address 1 : P. O. BOX 142
City St Zip WESTHAMPTON NY 11977
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. #R10-94-0069
Name Of Owner WINIARZ, DOROTHY AND MARIE
Mailing Address 1 P. O. BOX 138
City St Zip MATTITUCK NY 11952
Property Address 1 OAK STREET
City St Zip MATTITUCK NY 11952
Tax Map No. section 141 .00 block 1 lot 13.001
Cross Street HORTON AVENUE
Building Permit Number Cross Reference:
Issue Date: 9/15/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
0,1141/s
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1110® 1;
JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® r791 P.O. Box 1179
UI � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Vo® 1�, Fax (516) 765-1823
MARRIAGE OFFICER a,� I�� Telephone (516) 765 1801
RECORDS MANAGEMENT OFFICER ®l r
FREEDOM OF INFORMATION OFFICER ��//Irk
OFFICE OF THE TOWN CLERK,
TOWN OF SOUTHOLD j SEP 1-01964
1961
TO: Southold Town BuildingDe -'
Department ;• BLDG.DEPT. I
OF
FROM: Linda J. Cooper, Southold Town Clerk's Office 1"—Y"TOWN SOUTI IOW
DATED: September 2, 1994
Transmitted herewith is a copy of application No. 1244 for a Cesspool/
Septic Tank Construction Permit submitted by:
Cly Pit Properties Inc. for Dorothy and Marie Winiarz •
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 e/0 —
Comments: J2 i / Z ' C:90 a 57
Signature
Dated
I ,
OFFICE OF THE TOWN CLERK c��FFO1A-
Town of Southold �� Olj
Judith T. Terry, Town Clerk ;-' i; : Application No.
Town Hall, 53095 Main Road ,i. SEA` Construction
P. O. Box 1179 "''':1,, rJ Alteration
Southold, New York 11971
Telephone 01� 1 • d Residential 17
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE 1,9•2 ft Y
APPLICANT NAME: c A/17 /7// /2/ g2 1,1 t6,
APPLICANT ADDRESS: f6' 3e7 /t'2,
/ j,cX S 7 A9o,,P7/7 ry Al /,9 72
SEPTIC t CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION AjkL.c)
COGS PO o& + n7,/c. 7./94,1(..
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: )..)69,20-it 1 1 `e1AR) : (,,fir/)/4/Z2- ,
PO �j
OWNER MAILING ADDRESS: � p )! /3S1
,/til %?Tr>c e. Al)!
OWNER PROPERTY ADDRESS: ,/U/sAJC 5 ✓
TELEPHONE NUMBER OF CONTACT PERSON: 8o2J--;" S O 7
TAX MAP NO. : Section / 9/ Block / Lot 13 , /
CROSS STREET: 1749 Aim) 4- vs
BUILDING PERMIT NUMBER CROSS REFERENCE:
---- -ee----------
iot: ,--1"
Sig .t .re of Applicant
RECEIVED BY:
T wn Clerk's Office
DATE: V-9/9/14-
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J I
' SUFFOLK CO.HEALTH DEPT.APPROVAL
uS�`Z 1 �! O� H S NO
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N {� ry N• 9'29 2O 1 \ . "� STATEMENT OF INTENT
O I THE WATER SUPPLY AND SEWAGE DISPOSAL
•o•-• 'z` 4 I I SYSTEMS FOR THIS RESIDENCE, WILL
' �o�i ' `; 1�0 I \ - L CONFORM TO THE STANDARDS OF THE
F ➢ - i -- 255.74
- �1•� 1 �'" �, 1S' �s- pt2oao_ c .,2 I I SUFFOLK CO DEPT OF HEALTH SER VICES
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sEP'rIG J _ �- \ 2�• �l• �!\ ISI f
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OVER 200 TO 0.h �6- I-1t^,. L' -- .-
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' O. o 4 i SUFFOLK COUNTY DEPT OF HEALTH
ProP SEPTIC . s fir. Nrp SER VICES - FOR APPROVAL FOR
(WELL LOCH - zo _ _ ' I - CONSTRUCTION&Y
/�.,�UNIGNO'"JN) O TEST 470 LE ` -- _ - I DATE AU6 2 9 /�
``� O ,9O -- - - -e \ ;E to H S REF NO 1`` .�q _l/( c?
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APPROVED L+v
I 269.90 -_ I
r„ ` SUFFOLK CO TAX MA SIGNATION
1 �- - I DIST SECT BLOCK PCL
v I &POOLS --i ' - • -' V 1 Iccc IYI 15,',
' u! ‘, ;J, I \ , -/ I OWNERS ADDRESS
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TEST HOLE 1I STAMP
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SURVEYED — FOR. ^_/ I WELL SCALA '�O I \ EI OWN lor-eavamweam
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I �----- TOWN OF SOUT1-4OLD N.Y. ELEVA`tows Ii CANTOU125 REFER TO MEAL) =Ef, LEVE' I RINE TO
COARSE SAND 1 '”
FIECE IV
IED -- AMENDED AUG.2Sj I SEAL
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GUARANTEED TO THE QWNEres WATER IN� coge r r,��
AUG '29 1994 -
AS SURVEYED - ,I994 PALEBROWN s �{-t
RODERICK VAN TUYL•P C j i FINE TO c q�1,-) 1
S.C. DEPT. OF \- - /
; - ✓-- -7---:•`, ' eApsE SAKI
fir, N"Esu21,
HEALTH SERVICES �r;�=oY
LICENSED LAND SURVEYORS
GREENPORT NEW YORK
I. TELEDYNE POST N81329
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