HomeMy WebLinkAboutOats Thomas OFFICE OF 'ires TOWN CLEP, K
TOWN OF SOb'TEOLD
r~BETH A~ NEVILI~ ToWN CLI~U.K
P.O, BOX 1179
SOLtFflOLD. NI~V YORIC 11971
TelePhone
(63t) 765-1800
TOWN OF SOUTHOLD
Application No. ~)~
Construction 7
Alteration /
$10o 00 - Residential ~/
$;25.00 - Non-Resi dential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT NAME:
APPLICANT ADDRESS:
DATE
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP:
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION':'
OWNER OF PROPERTY: ~r~_~5 ~ ~ Ok
OWNER MAILING ADDRESS: 90 ~)~3~
OWNER PROPERTY ADDRESS: _(_~'e~.x-~
TELEPHONE NUMBER OF CONTACT PERSO~:,~/'
TAX MAP NO.: Section. J~- Block
CROSS STREET: ~)O~ ~/~
BUILDING PERMIT NUMBER CROSS REFERENCE:
Must be attached hereto before permit may be issued.
Lot ~ y
RECEIVED BY: ~,~ ~s
DATE: .... /Jb~ /~ 2.~ iOffice
Signature of Applicant
SURVEY OF PROPERTY
AT ORIENT
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW Y. ORK
1000-15-01-28
SCALE: 1"=30'
JAN. 22, 2(~02
le~rch f3, 200~ (revisions)
SCDJ-tS Ret.# R10-01-0202
'1
N
Z
LI3T 13
HOLE
s 80'36'0~
LOT 14
134.
0
LOT lB
(DWELLING>
wELL
PLAN
PERMIT I~R APPR~)V
S~GLE
AND C~NSTRUCTI~N ~F SUBSURFACE ~ WA~~~~n=s~n,~,
DISPBSAL SYSTEMS FaR SINGLE FAM[dY RESI~C~S , , , ' ~ ¢~ -- -
on the penmit to construct,
Etevations ore reFePenced to a~ assumed datum.' ~ ~ (6; ~'*~9~/ FAXff63t) 765-17
· =~N~ ~ ~ ~* P. ~~Y , .... ,,
LDT NUMBERS REFER TO 'MAP DF GREEN
ACRES AT DRIENT' FILED IN THE SUFFOLI<
CDUNTY CLERK'S OFF]CE BN ~PRIL ~, ]gE
pROPOSED ~IVEVAY