HomeMy WebLinkAboutPaulick %oFFO`,��® \
ELIZABETH A.NEVILLE �•� 4 �; Town Hall, 53095 Main Road
TOWN CLERK % o - P.O. Box 1179
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REGISTRAR OF VITAL STATISTICSPr/ 1Southold, New York 11971
MARRIAGE OFFICER ``may �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �__�Q1jig *6;61.°
1i° 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. 2974 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : DOUGLAS MCGAHON
Address 1: PO BOX 602
City St Zip CUTCHOGUE NY 11935
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 #R10-98-0124
Name of Owner PAULICK, WALTER
Mailing Address 1 300 TERRY PLACE
City St Zip RIVERHEAD NY 11901
Property Address 1 PARKWAY DRIVE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 109.00 block 5 lot 14.013
Cross Street GREENWAY DRIVE
Building Permit Number cross Reference:
Issue Date: 12/26/02 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
0
ELIZABETH A.NEVILLE ,t11,4 VTown Hall, 53095 Main Road
TOWN CLERK % o ‘ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS % i Southold, New York 11971
: 0 0 Fax(631) 765-6145
MARRIAGE OFFICER : # �1
RECORDS MANAGEMENT OFFICER =__'jlol $��� Telephone(631) 765-1800
FREEDOM OF INFORMATION-O_9PIICER - ���� southoldtown.northfork.net
, } OFFICE OF THE TOWN CLERK
ua6 E 2302TOWN OF SOUTHOLD
T Southold--T-ov uilding Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: December 18, 2002
Transmitted herewith is a copy of application No. 3095 for a Cesspool/Septic Tank Construction
Permit submitted by:
Douglas McGahan for Paulick
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: r .,4
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Signature
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Dated
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OFFICE OF THE TOWN CLERK 116„
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TOWNOFSOUTHOLD ; '.® 0 Application NO. qS
FT.T7ABETH A NEVIT.T.F,TOWN CTPRK • �•. G. P P
P.O.BOX 1179
r , � � Construction ✓
SOUTHOLD,NEW YbRK 11911'' I h =o • z
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�Q��•• $10.00 - Residential ,/
Telephone °,f�
(631) 765-1800 _ Qj -at ''
,,,, $25.00 -Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. .
•
Fee $
DATE DeZ,A
APPLICANT NAME: DOUait5 ilkt-CtifArQ
APPLICANT ADDRESS: 'NO - boa- C.Altr�b'i'4ar 11 3
SEPTIC ✓ CESSPOOL C/
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
5-'4C 7-71-"e_ /1 1 /n(
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: /tcffe3✓ `, j471P, - RQx)`k(
OWNER MAILING ADDRESS: 3co Ttizi p t-T-
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OWNER PROPERTY ADDRESS: 6 /3 1 712vDALE.,
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TELEPHONE
rTELEPHONE NUMBER OF CONTACT PERSON: 7?-3'1b27j r Dcu( Mc
TAX MAP NO. : Section C d (4Block 6 5 Lot IY- ()
CROSS STREET: £ALtra4 yew
BUILDING PERMIT NUMBER CROSS REFERENCE:
• Signature of Applii:nt
RECEIVED BY:
Tow Clerk's Office
DATE: la t(0-1
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M! T SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
OFFICE OF WASTEWATER MANAGEMENT
SUFFOLK COUNTY CENTER
RIVERHEAD,NEW YORK 11901
(631)852-2100
APPLICATION FOR EXTENSION, RENEWAL OR TRANSFER
OF EXISTING PERMIT TO CONSTRUCT SEWAGE DISPOSAL
AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING
Before completing this application refer to"Instructions to Renew,Extend or Transfer an Existing Permit for
Single Family Residence"on reverse side of this application.
•
1. EXISTING REFERENCE NUMBER R10-98-0124
2. TAX MAP NUMBER: District 1000 Section 109 Block 5 Lot 14.13
3. NAME OF APPLICANT Karen Luce Paulick and Walter R. Paulick
(If name is different from original applicant, see instructions for transferring a permit and complete section 6 below.)
ADDRESS 30 Terry Place, Riverhead, New York 11901 PHONE 631-369-3100
4. NAME OF AGENT (If not applicant) None
- r-_s cf.)
ADDRESS PHONEmr,' .—
5. DATE OF ORIGINAL APPROVAL 10/8/98 (If more than 6 years old, a new appl s ion Will b�• ilired.)
rr
6. TRANSFER OF PERMIT:..I hereby transfer all rights and interest in t above efered Amite new
applicant named above,
SIGNATURE OF ORIGINAL PERMIT HOLDER/AGEN
/ PRINT NAME James J. and Margaret M. Fallon DATE-1 /0-2
/02
ADDRESS 284 Chase Way, Manchester, NH PHONE
Application is hereby made to [ ]extend, [ ]renew, [X]transfer a permit to construct a water supply and sewage
disposal system for a single family residence in accordance with the application, surveys and plans submitted. I hereby
certify that I have examined the complete application and the statements therein are true and correct, and that all work
shall be done in accordance with all applicable Town, County, State and Federal Laws and Codes. "Any false statement
made herein is punishable as a misdemeanor pur
suant
tooSLL210.4 •, ew York State Penal,Law."
SIGNATURE OF APPLICANT/AGENTQ -Q-La DATE 6/26 /02
PRINT NAME Walter R. Paulick TITLE Owner
If you are making substantial revisions or modifications to a project that has already received a permit to construct from
the Department, or if the permit is more than six (6) years old, a new application will be required. Follow the
instructions as explained in `Submission Requirements For Single Family Residences' (WWM-041). Renewed permits
are subject to any changes in standards enacted after the approval date of the original permit.
DEPARTMENT USE ONLY
Permit is Extended/Renewed/Transferred Unt' /0-8-04 Number of Bedrooms Approved 171
Signature of Department Representative ' _Ad( 1 Date x`9-0 2_
WWM-104 (Rev. 03/01) PAGE 1 OF 2
16-1663 5/01