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ELIZABETH A. NEVILLE ���� �d • Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
O Fax(631) 765-6145
MARRIAGE OFFICER � �
RECORDS MANAGEMENT OFFICER �,_ 2Z, ogt. Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ `,,ssZs'
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4016-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WHALEN, TERENCE
Mailing Address 1 C/O EAGLE 'S NEST HOMES OF LI
Mailing Address 2 4 FERNWOOD DR
City St Zip COMMACK NY 11725-0000 ,
Property Address 1 THE STRAND
Property Address 2 PEBBLE BEACH FARMS
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 631-543-7123
Tax Map No. section 21 .00 block 5 lot 72.000
Cross Street THE GREENWAY
Issue Date: 3/08/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C� -
TOWN OF SOUTHOLD COG at
Appli'Gation No.4/d l�
F�LIZABETH A.NEVILLE,TOWN CLERK . ';. :;4 < $10.00 - Residi:ntia
P.O.BOX 1179s.
SOUTHOLD,NEW YORK 11971 �' :y"`'3 $25.00 - Non-Residential
• - Telephone OI �� "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 221 '- 1
Fee $ /1 , q
DATE 3/ fO
OWNER NAME: /tP /g P C Jv vl/ /NnL
4�
/74-41. /C s ,l4' 9- N®M/,-.F or Al
OWNER MAILING ADDRESS: /a /D r- MRN woo 0 /.L n. /
t /y/to /'c /1/_y' // 7 '2 a'
OWNER PROPERTY ADDRESS: 17/ /i c7%/t /l/V,U r/o,„/ /i' /44 r// J`/d el,r)
EAS iyOA/k1,✓ c' u ,710 lily
OWNER TELEPHONE NUMBER: 6 3 / -sys - 7/ 23 r,ti ,Aes /I/,,A.s%`/0A r
TAX MAP NO. : Section #/ 000 . Z / Block Jr- Lot 7 2
CROSS STREET: �/0
TYPE OF SYSTEM: Septic Tank New A Existing
Cesspool New P( Existing
Residential )r Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
3/19APvti " d/9 PP Si uo Applicant
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RECEIVED BY:
Tow'lerk's Office
DATE: 3/. /(2 (�
•
11111411114101.1W ,
SURVEYED FOR:- �,444,�s I,., �'� 1.1- / I H (. Ki pm. 'LEASE NOTE'
LOCATED AT • Fes''.iwbo�d , iv--I N ; ‘14 '•� p Y.
Sanitary system is not to be
LOT 8!0 �.t • ' �,. '- 'placed under driveway area.
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SCALE 1"—.4-14, liZ t�, SUY,'g C4.aI. $sEF i'OF x-
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. • �) FACAVATION INSPECTION REQUIRED
L 4 .. ®' r NA kJ,' FOR SANITARY SYSTEM
44
-4 6 • /3 a 31 ' 3. , 4'�. BY HEALTH DEPARTMENT God,.Si '
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vSURVEYED ( G 2.7 14:5.91- BY
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�N � (a WILLIAM R. SIMMONS III, L.S.P.C.
° ® 11 MEROKE LANE
a EAST ISLIP, L.I., N.Y. 11730
.
(516) 581-1688 Fax: (516) 581-1691
m t\,.zFILE NO. r2-',/,,74-13 PAGE GRID
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