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ELIZABETH A.NEVILLE _� Gy� Town Hall,53095 Main Road
TOWN CLERK co P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS %11-0 Southold,New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER y�Ql �aO� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4242-R Residential x Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner SMITH, WILLIAM
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Mailing Address 1 PO Box 702
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Mailing Address 2
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City St zip ROCKY POINT NY 11778-0000
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Property Address 1 10605 SOUNDVIE AVENUE
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Property Address 2
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City St zip SOUTHOLD NY 11971-0000
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owner Telephone No. 631-744-1039
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Tax Map No. section 54.00 block 5 lot 37.003
Cross Street KENNY'S ROAD
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Issue Date: 1/28/04 , Elizabeth A. Neville
-------- Southold Town clerk
(TOWN SEAL)
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O TOTCLERK F�
WNOFSOUTHOLDO\OC��F �j Application No.
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179 crs
SOUTHOLD,NEWYORK 11971 • $25.00 - Non-Residential
Telephone0.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. �1
Fee $ t
DATE /� 16__,x____
OWNER NAME:
OWNER MAILING ADDRESS: (�- C3CJ
ANCD-���r. P® ".%1'. &)-V 1177
OWNER PROPERTY ADDRESS: 0 6 Q S ...5,0 y d��l Q Z -Ave-
50
A Ve-
50Lk+�a�Id // Q7 /
OWNER TELEPHONE NUMBER: 63
TAX MAP NO. : Section ,j y Block Lot
CROSS STREET: /"'�).pY-\ ,r-\ S / G"\ 4a,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 4/New Existing
Residential `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.)
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Signature of Applicant
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RECEIVED BY:
Town Clerk's Office
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DATE:
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SURVEY OF, PROPERTY
5i-ruATr=: SOUTHOLD , N
TOWN: SOUTHOLD
SUFFOLK cOUNTY, N'Y W
SURVEYED Oq-01-qq
AMENDED II-21-qq, F
06-05-00,06-14-00,
06-20-01,01-05-01,07-13-01 S
08-13-01,08-I1-01,
FOUNDATION LOCATION 0I-30-03
FINAL 10-02-03, 10-16-03
SUFFOLK COUNTY TAX #
1000 - 54 - 5 - 31.3
CERTIFIED TO:CD
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NOTES:
■ MONUMENT
O PIPE � �1('�, o'J:o�n��f:
AREA = 3q,ggq S.F. OR 0 q2 AGRES
4 AD Juy"! 1!'I xnJlnpJl et n'"J"re^mm�r-
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ELEVATIONS REFER TO M5L N6VD'2q JOHN
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E gg E S LAND
ND S R EYOR
6 EAST MAIN STREET J1� L�1FJ J� N.Y.S.LIC.NO.GRAPHIC SCALE I"= 40' �
RIVERHEAD,N Y.11901 REF.\\Hp server\d\PROS\99-229i.pro
—�—� 369-8288 Fax 369-8287