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JUDITH T. TERRY
Town Hall, 53095 Main Road
TOWN CLERK % C:;$ T , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS td� aC �� Southold, New York 11971
MARRIAGE OFFICER t. goo Fax Fax (516) 765-1823
�y® ��®I�� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 762 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : ZURAWSKI, JOHN A. & PATRICIA C
Address 1 : P. O. BOX 79
City St Zip PECONIC NY 11957
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.
Name Of Owner ZURAWSKI, JOHN A. & PATRICIA C
Mailing Address 1 P. 0. BOX 79
City St Zip PECONIC NY 11958
Property Address 1 PRIVATE ROAD EAST OF EVERGREEN
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 108.00 block 3 lot 8.002
Cross Street MAIN ROAD
Building Permit Number Cross Reference:
Issue Date: 9/25/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY � �� Town Hall, 53095 Main Road
TOWN CLERK : oazP.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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„ 0�® �i�' Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK 2 2 ow
TOWN OF SOUTHOLD I5 Imo-
E
SEP 2.01991
To: Southold Town Code Enforcement Officer
From: Linda Cooper, Southold Town Clerk's Office BLDG. DEd •
TOWN OF SOUTHOLD
Dated: September 20, 1991
Transmitted herewith is a copy of application No. 783 for a Cesspool/
Septic Tank Construction Permit submitted by:
John A. and Patricia C. Zurawski
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 �1
Comments: ��,''ss
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Signature
liz.%\c‘‘
Dated
OFFICE OF THE TOWN CLERK ,,,
Town of Southold �,�' 'CvFFUiK`' di3
Judith T. Terry, Town Clerk ��' NCo�_. �'� Application No.
Town Hall, 53095 Main Road ' Construction
P. O. Box 1179z
w ryi+ ;
Southold, New York 11971 tt` . .` Alteration
Telephone ." �/'� $10.00 - Residential
(516) 765-1801 ��o.� ��
$25.00 - Non-Residential
..ills
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $/d
DATE SCS% / 9 , j 99/
APPLICANT NAME: jO//N 'Q • £ I 7Ricci C• Ztj 'iiWSk(
APPLICANT ADDRESS: /7O. / ox 7 9 AJO,PTi-I A9d.
P6coiv/G , N. q. //q -
SEPTIC
/qSEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
l\ (4) FvC-t7vt)47-70 / 7-/C /4-- 6
e
LOCATION MAP: Must be attached hereto before permit may be issued.
• LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Th//A! ,. 73/47-Ric-IA) C. EC' IQ/a Sk1
OWNER MAILING ADDRESS: PO, 80x 79 AiO 7 -/ 104,O
I9li7tO iv)c I'U . L/. /165- P
OWNER PROPERTY ADDRESS: PO v/,9-; / 0/4-0 1--"2-AS Q�
v ; 2 E(` /1/ &1i 7Zl 6 LC_
TELEPHONE NUMBER OF CONTACT PERSON: 78(k- 793
TAX MAP NO. : Section ) Q g Block 3 Lot V.
CROSS STREET: Er6-72
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature Applicant
RECEIVED BY:
Town lerk's Office
DATE: „A/21- /� , l c2 cV
L
1 -- I� ��
3o /is. SUFFOLK CO.HEALTH DEP1:APPROVAL , '
14/P _ �1JTILC ; / H S. NO. t w,
- (2EIDeNOE-) /
/7"-
,•,.••‘
Lo ' (VACANT)1UIf lU ,t y
^‘:1''`. -30 ( SINGLE_ E1\MILY DWELLING ONLY _ ,
-, N.61314dE- p 186 ° p ND
rALV t�tP6 ••' CI-It25ZY TWEE" 170 s2`�0° 5 EX IRES l V�O , Hr'. ::) FROic9 DATE OFAFF RO JAL
MAP OF Pi2OPE12TY N
�. ` � �A¢Ll` J � STATEMENT OF INTENT
R
OSAL
SURVEYED F=orL v '(11 ! •,-,`•-•'•('4 i�YO01 o 'o _ , - r tp�0 s• o� co R. SYSTEMSTHE E FOR SUPPLY
THIS D RESIDENCSEWAGE E WILL
r L`•-
i I \ •
J� ,}� El
/� /� 2i �` 00$, - ES - U' _ .--.- , ,5 CONFORM TO THE STANDARDS OF THE
• 11)1-1 \ L1 FATZI I I�L1i / t'' „• 1 `.: - m - 20 y� SUFFOLK . F HEA ILTH SERVjOES
' I \ ! 1 1 �J 1 C• i 31' 3 --1, .#'' (S) �C7e,.�� ,
Z C��A Y V II 1,n• AF p/itcV•4AD5) -.#' '� `' '`-" �. APPLICANT
hs� - .,1` - •,,.;...v ••1 ` SUFFOLK COUNTY DEPT I OF HEALTH
_— - �` 1.7:4-
_ l v' "' - - -- - CL.
Al- 1 I p ! A'�7�y ;' r - - - - C) ,, ) SERVICES - FOR APP OVAL OF
io- kj z Q CONSTRUCTION ONLY �� �y
- ID CUTCMOGUE ''+ DATE air �� t �$�,
2 ' TOwN OF OUTI-101.D 1\1`s! ' 4o 0 1 4 (GOEtt FIELD) - v H S REF NO `�/-�Q ��/ , .rff�
1---- .a W i \U. Q y 3° APPROVED ( iI14af.2 .\
-, 3
Q lt 8�' r SUFFOLK CO.TAX MAP DESIGNATION'
• U - ' •�1 g -r2`.. O
,r ,4L_E / DIST. SECT BLOCK PCL.
L: 01 �;' h N r Irw !Tie , 3 8.2LI_ 1
7) °N t\ , , Z N r _]00 �,_�% OWNERS ADDRESS:
n10C^,Df'IEL J ter. 5Q` • PRIVATEe--- -,-_,�-r' _`- 25; ;f 6N or iititra �vc•0-7°----d� r� •
�OR 64:ROFID±\I��Q QOlC`7Q I
:Cci:!rar - •" ` " -t1:63'40'40"E.t4150 2.7-:-..t-•' •1.S,63°'i}0`4O'W.•. t 25;` 2OAC --, 4 . 2 ` PECON1C A(!•/':h195$> .
'1 `, !t1 ! r pnil . r
w 3 i ,4 • , • _-. - r':'\ , .. _ r ; DEED. L . P.
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KL N s .., 2S 15 TEST HOLE STAMP
� tn, AtJNutdZiATA 5 ,-( r-'5 �;(? n 'T t "r- ,th '�•= ,a•t,
N. 'N L vacAN 1) `tii : 2t.sIc1E.rJtt_ 5 ?i �f i$ �o �a�, i�tda'a t3a l��:z
its
W I.1.a F._r liiiMCE. =ttJo,
WLY �-�• ti� _ I 20 -------_- L_DAN, _,' ,nD•Em ecnen'c
PLEA E' I I r 21,i0U I_E-F_t_h 7U MEAN SEA LEVE: --.� .,�-. c•,,,
0 , . S , 10TF `
o I.,�,a. 9,( E.7, ,— -- Sanitary syst�tn is not to be SUFI�oi_u .:u_,•ax No. Woo-tc�a-3 -S.V. •3ANL?�� . ,-,,h,� • --,.
-..f I placed und9i`driveway area. 't-.Ay> `-_ ! .
S 1 " WELL COVENANT REQUIRED :AND
is 3I� ,// PRIOR TO FINAL APPROVAL.
' / - i' ::
- -"
17, SEAL
3U Ai, lltrl'L 1:U 'i';:.-1
CAI,E 't •
p• . E�titrK AND --
AQEA` 325E AC aF N.Y.,IrJG, AS iSI2VEYE(7 APR 8,19 91 'i4 .-1 , .,,
I RODERICK VAN UYL,P.C. `t' "
1,/,‘,/ w86•''�1 U'MCNUMk NT 12. V --T
5'0� •k�-�o , ` AMENDEDJUN'E 20, 1991- LICENSED LANDS SURVEYORS
S?
O BS \ - _ ' _� JUhlE 27,1491 GREENPORT NEW YORK
TELEDYNE POST N61137 . ••S r'.'. , ` -