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JUDITH T.TERRY 1°= Gy •
m Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Pr, Southold, New York 11971
REGISTRAR OF VITAL STATISTICS O � Fax(516) 765-1823
MARRIAGE OFFICER ‘tk O���� (516) 765-1800
41,RECORDS MANAGEMENT OFFICER o� �� � Telephone
FREEDOM OF INFORMATION OFFICER "t
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1715 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : SCHEMBRI HOMES INC.
Address 1 : P. O. BOX 163
City St Zip WADING RIVER NY 11792
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 #R10-97-0115
Name Of Owner SCHEMBRI HOMES INC.
Mailing Address 1 P. O. BOX 163
City St Zip WADING RIVER NY 11792
Property Address 1 PLUM ISLAND LANE
City St Zip ORIENT NY 11957
Tax Map No. section 15.00 block 5 lot 6.000
Cross Street
Building Permit Number Cross Reference:
Issue Date: 8/15/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
4
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JUDITH T.TERRY ;�=0 OGy` Town Hall, 53095 Main Road
TOWN CLERK , y P.O. Box 1179
v �` Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O �1
MARRIAGE OFFICER V*" �1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = ( ilig *a ...
..� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ��_�,�r��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: August 14, 1997
Transmitted herewith is a copy of application No. 1786 for a Cesspool/
Septic Tank Construction Permit submitted by:
Schembri Homes
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.
Thank you.
Cf-( 3w67-4---
Linda J. Cooper
* * * * *
* * * * * *
I have reviewed the application
n and location map of the project cited above
and make the following rec mendations:
APPROVE iV
DISAPPROVE
Comments:
gnatur
Dated
,-
OFFICE •OF.THE TOWN CLERK """
Town of Southold ,�''�C��FFUL/r`'�
Judith T. Terr Town Clerk �'1.14! �/ Application No./ 7 c� J
Town Hall, 53095 Main Road4 'ra Construction
P. O. Box 1179 ` = Mr+ ` Alteration
Southold, New York 11971 s
Telephone
.......v., _sr
��O�,i, $10.00 - Residential �,
(516) 765-1801 _ 1
,, $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 '7
APPLICANT NAME: 511/Air\
APPLICANT ADDRESS: (i' l (-0--)2
G
SEPTIC CESSPOOL(
—
DESCRIPTIOF PRPPOSE; COISTRUCTION OR ALTERATION illui
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION// OR ALTER ' ION:
OWNER OF PROPERTY:_______ 5 (,/h _ _ -
OWNER MAILING ADDRESS: 5,4, d,
OWNER PROPERTY ADDRESS: X, 1 41/
A 01
---- '�
— -
TELEPHONE NUMBER OF CONTACT PERSON: P,2_9_ SalC
TAX MAP NO. : Section ( S-- Block o s— Lot °`s'
CROSS STREET: PJ _62Qcf /"—____
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY: 0 K—>i
Town Cler 's Office
DATE: F7/ Vf/ e2 --- — __
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Received/(•---i7 suffeve county POR MAXIMUM OF y BIiDROOMS
AUG 0 6 1997 EX><'t I YEARMICRIQATi OF APPR i 1 VAL
DePt Of Health � f
THE WATER SUP.
PL Aterer/4M int.
8 r/
DISPOSAL FOR THIS RESIDENCE
WILL CON FROM TO THE STAND- V 4"1.- 't-46 L' 1
ARDS OF THE SUFFOLK COUNTY
DEPT.OF HEALTH SERVICE&
.-►..E 49, 3444-
Unauthorized alteration or addition to this document is a violation of Section 7209 SURVEY OF: 8
of the New York State Education Law.
Certifications indicated hereon shall run only to the person for whom it is prepared ll n i� t
and on his behalf to the Tide Company, neesrof the l Governmental Agency and Lending w A m v O ff! oei w-,/-rk f i i—
Institution listed hereon,and to the assignees of the lending institutions or subse-
quent owners. rf ,�..� t
Copies of this document not bearing the professional's inked seal or embossed Op'E.1 r PO s„#T'1 I 0 w o nieg ,.(
seal snail not be considered a vat true copy. F� Ir 1 1 `'T ,�!""'�
The offsets(or dimensions)shown hereon from structures to the property lines are / ✓
for a specific purpose and use and therefore are not intended to guide the erection of kt1 Ffa 1,.K L at44- `6 EW •1 0 .
fences,retaining walls,pools,patios,planting areas,addition to buildings or any other
construction.
The existence of right of ways and/or easements of record,if any,not shown are
not guaranteed. ,t� -' ,fir.VEY DATE:• S 114 0/ SCALE: I ": in 1
CERTIFIED ONLY TO: DEST)�s" F . ;.
DESTIN G. GRAF
/7LF{-e." ►21 ' L ' i
LAND SURVEYOR
tx$EN;E
By ,; .,/
�.J� 73 WOODLAWN ROAD
DESTIN G.GRAF N.Y.S.LIC No.50067 . ' ROCKY POINT,NEW YORK 11778 !r-1-1.11..
TAX I.D.No. Gb0 - I-: O - O�v
( - slot,At. '' PHONE(516)821.3442
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