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JUDITH T. TERRY ;� ` < Town Hall, 53095 Main Road
TOWN CLERK s T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER e3� �` Fax (516) 765-1823
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A.„4.1== to Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1774-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner DBM CO.
Mailing Address 1 443 MAIN STREET
Mailing Address 2 P. Q. BOX 2130
City St Zip GREENPORT NY 119/14-0000
Property Address 1 470 MOCKINGBIRD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-2223
Tax Map No. section 55.00 block 6 lot 15.055
Cross Street TUTHILL ROAD EXT.
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK CO Fai
Town of Southold ��w.{. .y xCQG' Application No. /771
Judith T. Terry, Town Clerk µrv, `��
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179
$25.00 - Non-Residential
Southold, New York 11971 O ® r ��`•
Telephone 10 0 "9
(S16) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /D—I 9/
•
OWNER NAME: .D6 /1 •
OWNER MAILING ADDRESS: /3 > • ®. 4ç7�z1 3 0
OWNER PROPERTY ADDRESS: g 7 D O
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OWNER TELEPHONE NUMBER: V5-1ly - ST7 7- )--)--V--3
TAX MAP NO. : Section LS BlockBl� 6 Lot /SSSS
CROSS STREET: l ,&d•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ✓ Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
-DATE: "
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ADEPT.OF
44 ISSfRVICES '
SURVEY FOR
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES JOHN S. ROSS Q MARGUERITE ROSS .- `
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SI_ LE FAMILY DWELLING ONLY LOT NO.49,DHIGHPOINT MEADOWS,SECTION THREE" •
DAISEP R 0 1991 HS REF NO. 9D-SD-/NCO AT SOUTHOLD DATE. SEPT 24,1991
The sewage disposal and water supply facilities for this TOWN OF SOUTHOLD SCALE i".40'
location have been inspected by this Department and/or NO 91 - 0819
SUFFOLK COUNTY, NEW YORK
other agent s an found to be/satisfactory. -
1 _ ?E AU AUTHORIZED ION OR ADDITION To THIS CERTIFIED TO. :lk� -
tirR"' ` SURVEY G A VIOLATION OF SECTION 7209 OF THE JOHN S R. .y
Chief of B reau of Wastewater Management NEW YORK STATE EDUCATION LAW - MARGU - �+-
NCOPIES OF THIS SURVEY NOT B[ARMG THE LAND TICO- {it gyp•=ANNIE a. 'f`
SURVEYOR S INKED SEAL OR EMBOSSED SEAL SHALL
NOT SE CONSIDERED TO BEA VALID TRUE COPY RD * Y O#
NGBARAN TEES INDICATED HEREON SHALL RUN ONLY TO r •
HEALTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUCT THE PERSON FOR WHOM THE SURVEY IS PREPARED 0 Oce
AMD ON HIS BEHALF TO THE TITLE COMPANY,GOVERN- *
N NEAREST WATER MAIN 111 * N SOURCE OF WATER PRT*TE_PUBLIC_ MENTAL AGENCY AND LENDING INSTITUTION LISTED ffi A -
NSVF CO TAX NAP DHT JOAQ SECTION_5°—BLOCK�LOT ISS5 HEREON.AND TO THE ASSIGNEES OF THE LENDING T�I
N THEME ARE ND DWELLINGS WITHIN 100 FEET OF TINS PROPERTY INSTITUTION GUARANTEES ARE NOT TRANSFERABLE `•lr 3
OTHER THAN THOSE SHOWN HEREON TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT -Ci-- .
N THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENCE OWNERS ''
*DISTANCES SHOWN HEREON FROM PROPERTY LINES
WILL CONFORM TO TIE STANDARDS OF THE SUFTOLK COUNTY TO EXISTING STRUCTURES ARE FOR A SPECIFIC •
OF HEALTH SERVICES PURPOSE AND ARE NOT TO BE USED TO ESTABLISH '• 4 der i
APPLICANT. •••••0{--- vA Co PROPERTY LINES OR FOR THE ERECTION OF FENCES ••,'4WD SUQ�c40% _ .
ADDRESS o (vLu21�j •
�{v_rz,nur+(kit 041' y77-2,2.23 YOUNG & YOUNG 4400E TT oN� PRAVENUE
NOTE+f=MON UMENT •
ALDEN W YOUNG,PROFESSIONAL ENGINEER
SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF AND LAND SURVEYOR N Y-S LICENSE NO 12845
SUFFOLK COUNTY ON MARCH 19,1990 AS FILE NO.8912.
HOWARD W YOUNG, LAND SURVEYOR \
o NTNG LOCATION OF WELL(W),SEPTIC TANNIST)SCESSPOOLS(CP)SHORN HEREON NYS LICENSE NO 45893
ARE PROM FIELD OSSERWITIOMS AD OR DATA OSTANED FROM OTHER S E S
BRARDIS E.SONS INC.
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' ;• SEP. 26 1991
•
' LEPT.OF • •
:►_;N 'SERVICES -
SURVEY FOR - - _
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES JOHN S. ROSS 8 MARGUERITE ROSS •
--- SI_NGLEFAMILY DWELLING ONLY LOT NO.49,"HIGHPOINT MEADOWS,SECTION THREE"
DA1SFP 2 0 1991 HS.REF.NO. 90-SD-/PO AT SOUTHOLD DATE SEPT 24,1991 -
The sewage disposal and water supply facilities for this TOWN OF SOUTHOLD' - SCALE• I 40'
location have been inspected by this Department and/or SUFFOLK COUNTY, NEW YORK NO 91 - 0819
other agentnIess an found to be satisfactory.
St- (1.. C,,Z. " 'E N uNAUTNORIZED ALTERATION OR ADDITION TO THIS CERTIFIED TO. :j��
UrSURVEY W A VIOLATION OF SECTION 7209 OF THE JOHN S R i
• Chief of B reau of Wastewater Management HEW YORK STATE EDUCATION LAW MARGU - ep$$e
N COPIES OF THIS SURVEY NOT REARING THE LAND TICO- ;-R. •-Altlr a. f`
SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL
NOT RE CONSIDERED TO BE A VALID TRUE COPY D O,�
NGUARANTEES INDICATED HEREON SHALL RUN ONLY 10 O�1' �' jO O
HEALTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUCT THE PERSON FOR WHOM THE SURVEY IS PREPARED
AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERN- 4, 41
N NEAREST WATER MAIN—MI • N SOURCE OF WATER PRI5 TE_PUBLIC_ MENTAL AGENCY AND LENDING INSTITUTION LISTED
N SUFI,CO TAX MAP DHT 1000 SECTION...n_OLOCK LOT 15$5 HEREON,AND TO THE ASSIGNEES OF THE LENDING �,
11 THEM ARE MD OW[LLIIOI WITHIN 100 FEET OF THIS PROPERTY INSTITUTION GUARANTEES ARE NOT TRANSFERABLE k1s^�,�I T
OTHER THAN THOSE SHOWN HEREON TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT -�C,45x._
M THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENCE OWNERS
WILL CONFORM TO THE STANDARDS OF THE SUFFOLK COUNTY DEPARTMENT N OI STA MC[S SHOWN HEREON FROM PROPERTY LINES �/
OF HEALTH SERVICES TO EXISTING STRUCTURES ARE FOR A SPECIFICii0r JU(
4
APPLICANT. `' Z CoPURPOSE AND ARE TO BE USEDECTO ES TARLISN
}n•J �. PROPERTY LINES OR FOR THE ERECTION OF FENCES �•�%�D�S,�E•(,
ADORES! {-o f'�usi a 12 o -
� C7ur+w . It9a�L y7rz�.z3 liiYOUNG a YOUNG �OST oN� AVENUE
NOTE:•'MONUMENT
SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF ALDEN W YOUNG,PROFESSIONAL ENGINEER - '
SUFFOLK COUNTY ON MARCH 19,1990 AS FILE NO.8912. AND LAND SURVEYOR N Y.S LICENSE NO 12845
$ HOWARD W YOUNG, LAND SURVEYOR' ' - '-
N THE LOCATON OF WLLL(W),SEPTIC TANK(ST)S CESSPOOLS(CPI SHOWN ME RfON NYS LICENSE NO 45893 - - - '
ME FROM FIELD OBSERVATIONS YID OP DATA°STAMED FROM OTHERS •
C.
BRANDIS A SONS INC. , -