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ELIZABETH A.NEVILLE e�� �°�' Town Hall, 53095 Main Road
TOWN CLERK ` ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ® . � ��,, Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER =_ ®� ��®��� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER .#'� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 2750 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : THEODORE PETI KAS
Address 1 : 225 STEWART AVENUE
City St Zip BETHPAGE NY 11714
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-01-0146
Name Of Owner BMA CONSTRUCITON
Mailing Address 1 225 STEWART AVENUE
City St Zip BETHPAGE NY 11714
Property Address 1 MINNEHAHA BLVD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 87.00 block 3 lot 11 .000
Cross Street
Building Permit Number Cross Reference:
Issue Date: 3/11/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
n
Will
I oil SAFFOLAr ".... 2` 2 5°
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ELIZABETH A.NEVILLE 1/����o Gy �; Town Hall, 53095 Main Road
TOWN CLERK ` o - % P.O.Box 1179
ny $ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS :144 ' �yC,,�� Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER =___®1 41, ��®�0� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ei�� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD r";) ff in
(U� r ', vi—
IT
TO: Southold Town Building Department !�'t r tl Fe 2 5 j►,� ; U)
FROM: Linda J. Cooper, Southold Town Clerk's Office '" Dt r,' '--
TC�',i__ Cc-_.`•: :�i OLD
DATED: February 22, 2002
Transmitted herewith is a copy of application No. 2846 for a Cesspool/Septic Tank Construction
Permit submitted by:
Theodore Petikas for BMA Construction
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.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: (:: ��
,
/1(1-e44
Signature
11-f-erceicd4-
, )---7/2-6,70 2_
Dated
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OFFICE OF THE TOWN CLERK ', `�••••••„.,,
Ri.r7�sETH
TOWN
.NEWT r TOWN CLERK I�4 0-4 D�I�4O!/....
‘ Application N o S�
P.O.BOX 1179 �� j �
SOiTtHOLD,NEW YORK 11971 i _ ; Construction
y� Alteration
Telephone 0,� ��re: $10.00 - Residential L
(631) 765-1800 ----- (41 41 �,,r'� • $25.00 -Non-Residential
-..ss
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION •
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $ •
DATE , 9_, _ 02____
•
APPLICANT NAME: . ---10,,35-0-,35-0- 0 R-G_______Y .� t Irk xlt---K
APPLICANT ADDRESS: 2_?.._C (2-/_gevo.,11- . 0,9_
5'()5t(1) Int--5 - r( 71C-\
SEPTIC CESSPOOL 9
DESCRIPTION OF PROPOSED CONSTRUCTION OR ATERATION
/tIO i �
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: (Rjti4, (;_.14(
OWNER MAILING ADDRESS: S-4ettjclfri
c--3-,1/4-P6Tte___ II 7cy
OWNER PROPERTY ADDRESS: /1//A,,)*&47114....114 f X17 `
TELEPHONE NUMBER OF CONTACT PERSON: _(j�, -73/— 2244”
TAX MAP NO. : Section R ..7 Block I O 3 Lot ,/' .
CROSS STREET: ® (A/4/
BUILDING PERMIT NUMBER CROSS REFERENCE:
-' _/l �
/ Signa bre of Applicant
RECEIVED BY:/°- V
Town Clerk's Office
DATE: / "a t d t _
u
SUFFOLK COUNTI DEPARTMENT OF HEALTH SERVICES
\ I PERMIT FOR APPROVAL OF CONSTRUCTION FOR A
g -IN LE FAMILY RESIDENCE ONLY
-I DATE l/( I/D r • /0-0t-e/g
H ` N .
i APPROVED /'v
FOR MAXIMUM OF BEDROOMS
EXPIRES THREE YEARS FROM DATE OF APPROVAL
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