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ELIZABETH A.NEVILLE ,i$14`� \ Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Z Southold New York 11971
REGISTRAR OF VITAL STATISTICS V. Al '
MARRIAGE OFFICER
O � Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER - y O�ileg Telephone(631) 765-1800
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FREEDOM OF INFORMATION OFFICER ' ‘.411 #,,'' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 /or Non-Residential @ $25 Application No.4/o2e�
Permit No.
Owner Name E avid W Y ,Jc F - i ZS 2,
Owner Mailing Address (070 ies •
Ma tf i'-f-kok N y 11152.
Owner Property Address (0 70 11,6reS4 -Dr
Mt�l' Ny jlgtiz-
Owner Telephone No. 6.3/ ?
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Tax Map No: /Jai)
Section /1 Block /3 Lot t
Cross Street tkt4) ucf=1(k Ave--
Please check each that applies: New Construction
Alteration to Existing System x
Residential )G Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system.to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Ai 1/ /,
77S3 . ,
ignature of Applicant ate
Received by:
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•:MONUMENT
Lot sued/vis/oN NAP f/GED IN THE Off/�
7 4 OF TIlE CLOP Of SIJFFO, C4'TV 0
JAN. ZS, /965 AS NAP NO4256.
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5.87.e/91201E.\ • -,s. — 1l51" ' [ l
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Q ~ `\\ r~I!' ; : h j.. `-. 404. Mq/970 400 OSTRANDER AVENUE.
' ` a s. 1
h k h OCT.4,1972
Q sw*.is. x r �' _ 1 `a . ALDEN W. YOUNG •
_- (i. • h ha** !U \\ , \., .� \ PROFESSIONAL ENGINEER ANO
V L.T F.,,,„
\ ; ��(.r \` LAND SU$VCYOR. N.Y.S. LIC. ,s ,12043
a . v qJ 'v1) ' 2e_`-tr_ss.a• Z.c SURVEY FOR:
0 • t7.1 , *4'= Q GARY ETTLEMYER 8 V IRG
• N • m . I 711 w (f) LOT 15 u DEEP HOLE CREE
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1.... 1 MATTITUCK
r- SPS i.o;i f��� i.�
izi + /4187./9'20"w. /82.00 , .' TOWN of SOUTHOLD
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Lot /4 SUFFOLK CO., N.Y.
SCALE: j 11 = 40'
1 DATE:JULY I