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JUDITH T. TERRYy{ ;� Town Hall, 53095 Main Road
TOWN CLERK ® ma �, P.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 � ����! r
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1164 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ANTONE J . WYSOCKI, JR.
Address 1 : P. O. BOX 29
City St Zip ORIENT NY 11957
Descripton of Proposed Construction or Alteration
ALTERATION - REPLACE COLLAPSED POOL
APPROVED. EXCAVATION INSPECTION REQUIRED.
Name Of Owner WYSOCKI, ANTONE J., JR.
Mailing Address 1 P. O. BOX 29
City St Zip ORIENT NY 11957
Property Address 1 MAIN ROAD
City St Zip ORIENT NY 11957
Tax Map No. section 97.00 block 2 lot 4.000
Cross Street BRIDGE LANE
Building Permit Number Cross Reference:
Issue Date: 7/20/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•146.C31 tf Lir Cy; I 4
JUDITH T. TERRY % Z - Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �" Fax Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER =_dr®1 1�••1, Telephone (516) 765 1801
FREEDOM OF INFORMATION OFFICER ,..wiii,,<1'
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OFFICE OF THE TOWN CLERK s § e 11 if 1 !'
TOWN OF SOUTHOLD
.RJI_ 5 . li•1 I_.,..'
TO: Southold Town Building Department
FROM: Linda Cooper, Southold Town Clerk's Office
T�DWSO� �®LD
DATED: July 7, 1994
Transmitted herewith is a copy of application No. 1208 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Antnne J. Wysocki Jr. ,
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
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed -`
above and make the follp,Qving recommendation:
APPROVE - . _y' . N.
0
Vttlit
DISAPPROVE - G v9
COMMENTS:
RECEIVED
JUL 2 0 19944.4.. , ' ..--
ignatuf
Town Clerk Southold
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OFFICE OF THE TOWN CLERK S\WFU1A
Town of Southold g� •"- /
Judith T. Terry, Town Clerk ,g(.;;;'
,t L Application No` °Z�
•
Town Hall, 53095 Main Road c ;: sem'_ '`` Construction
P. 0. Box 1179
Southold, New York 11971 O ' 0�� Alteration
"0 Residential
Telephone _ •
l
(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 $ n
DATE / ./-1 F y
APPLICANT NAME: M�Qhi� W YJ d c / T
APPLICANT ADDRESS: j% 5D, fe9( "7 /9aFC 07Ve
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
6A 7(.=' 62-7-1'a 1-! -
LOCATION MAP: Must be attached hereto before permit may be issued..
• LOCATION OF PROPOSED'CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: S717--//14._
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: S 6-112
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO. : Section 9'7 Block Lot
CROSS STREET: � �—
BUILDING PERMIT, NUMBER CROSS REFERENCE:
a/f7ay. °
gnatur of Appl• ant
RECEIVED BY: b
Town Jerk's Office
DATE: 7_ - � °
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