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SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Aesidential @ $10 or ❑ Non-Residential @ $25 Septic Tank ❑or Cesspool L�3
Application No. Permit No.
Applicant Name: 1 It/I
Applicant Mailing Address:
Brief description of Propsed Construction or Alteration: eve,' a �✓ r�,� d
Location of Proposed Construction/Alteration:
Owner of Property: �S�`a le e
Owner Mailing Address: /9 57 ��^/ ��. �/7
Property Address:
Name and Telephone No. of Contact Person: Pa
Tax Map No.: Section: 31Block: Lot:
Nearest Cross Street: al_/
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DE t NT APPROVAL.
Siganture df Applicant Date
Received by:
a
A V
P'
SURVEY OF
LOT 79 AND P/0 78
�o MAP OF .
a
J��j� GARDINERS BAY ESTATES
° SECTION TWO
u'O j / FILE No. 275 FILED SEPTEMBER 23, 1927
y� $ _ ���j SIT UA TE
4. �� `� EAST MARION
"� TOWN OF SOUTHOLD
O 4V �� � SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000-31 — 15- 1 0
:, \ ', O ,� SCALE 1 f f=20f
O e. 00• ? 6rn `�' FEBRUARY 28, 2014
,: a3". � \ � �, i / AREA = 11,474 sq. ft.
° v 0 (TO TIE LINES) 0.263 ac.
41
° ^ I w R7�/ ,1 s9. t-�� , �� STANDARDSPREPAREDI R FOORD/WCE THE MINIMUM
BY THE LIJALL . Ap
L(7 N I w c
TFOR L
ITLE Assoc SUCH $S PS@ �E D
O °� \ j �,y0, AFT
A.
O < • / / '18 SC3�(,•7
,A'�0 I �j�`� Y Np�SE aY1.7 N.Y.S. Lic. No. 50467
°.
° � UNAUTHORIZED ALTERATION OR ADDITION
y° TO THIS SURVEY IS A VIOLATION OF
n SECTION 7209 OF THE NEW YORK STATE
• 0 ��y� 4�0 EDUCATION LAW _ Nathan Taft Corwin III
°4. GVH Oy Q � THECOPIELANDFSURVEYOR'S INKED SEAL. ONOT R
• < �v1 ePG -O S�[°�g 1i 1 TO BETA VN EA TRUE CNOT OPY. BE CONSIDERED Land Surveyor
4 •� ONS O ^°boo J I��; ONLY TO TONSPERSONO RHEREON WHOM THE L RUN
• v < �' O IS PREPARED. AND ON HIS BEHALF TO THE
4 .o,•mm S TITLE COMPANY. GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layou
° .
V . J LENDING INSTITUTION LISTED HEREON. AND
u ° TO THE ASSIGNEES OF THE LENDING INSTI-
TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. PHONE (631)727-2090 Fax (631)727-1727
a' v° 0. OFFICES LOCATED AT MAILING ADDRESS
• y THE EXISTENCE OF RIGHTS OF WAY 1586 Main Road P.O. Box 16
a �,L AND/OR EASEMENTS OF RECORD. IF Jamesport, New York 11947 Jamesport, New York 11947
v - ANY, NOT SHOWN ARE NOT GUARANTEED.