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ELIZABETH A. NEVILLE Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
M Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS IOy
At
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT Q
APPLICATION 4 1
CONSTRUCTION or ALTERATION PERMIT V "
CESSPOOL or SEPTIC TANK JJ
Residential @ $10 ? or Non-Residential @ $25 Application No. `T
Permit No.
~1~f1/M4S:5C4L%A V 0'*- :
Applicant Name 8rzWe.4AYOIV iC>(CAVAT t N 6 ~ RI A AI 924 b00
Applicant Mailing Address /SO r,4,f//t Q71 w- 45-r
hDl C-r QtVe-PL IV V 11412
Septic Tank or Cesspool ?
Brief Description of Proposed Construction or Alteration Aypri t t91U 'PD Lsk jST /C,7
5 sntm
Location of Proposed Construction/Alteration:
Owner of Property: A'oS5 ASSoG L L C
Owner Mailing Address: 871;- C 20 iN N L A A) D tAtt.E
CkATtVA06kEr Al/ y. ) 935
Owner Property Address: /260 120au.rs'H AVM:
KTCt6o(autS /V.V. I)43S-
eKvIrtK 14 AaKIN LONSraNe770W1 - Sit- 'Q7l-6T7I
Name and phone number of contact person s ' s~e4s -73 4 - V 2 V o
Tax Map No: Section /o3 Block Lot /0
Cross Street 10,7K/91 /Z 17.
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
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Signatyr of Applicant 7NIo4s Sc.44 A Date
Received by:
***RECEIPT***
Date: 04/04/14 Receipt#: 166858
Quantity Transactions Reference Subtotal
1 Septic Permit - Construct - Resid. 4230 $10.00
Total Paid: $10.00
Notes:
Payment Type Amount Paid By
CASH $10.00 Adjs, Associates Lic
Name: Adjs, Associates Lic
875 Crown Lane Lane
Cutchogue, NY 11935
Clerk ID: CAROLH Internal ID: 4230
g,. SURVEY OF PROPERTY
N AT FLEETS NECK
NEAR CUTCHOG UE
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
1000-103-11-10
s• SCALE.- 1'= 30'
ALLY 30, 2013
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AREA= 15,000 SO. FT. ~SGf-~~s 4WS a~
ANY AL7ERA7701V OR ADD177ON TO THIS SURVEY IS A WOLA77ON 04-% j~ O N.Y.S. LIC. NO. 49618
• OF SEC77ON 72090E 7HE NEW YORK STATE EDUCA77ON LAW. 0•
O ECONIC YORS, P. C.
EXCEPT AS PER SECTION 7209-SUBDIWSFON 2. ALL CER77177CA770NS G 9
HEREON ARE VALID FOR THIS MAP AND COPIES 7HEREOF ONLY IF (631) 765-5020 FAX (631) 765-1797
SAID MAP OR COPIES BEAR 7HE IMPRESSED SEAL OF THE SURVEYOR P. 0. BOX 909
WHOSE SIGNATURE APPEARS HEREON. 1230 TRAVELER STREET
SOUTHOLD, N. Y. 11971 F13-219