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JUDITH T. TERRY • Town Hall, 53095 Main Road
TOWN CLERK ® rZ : P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
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MARRIAGE OFFICER /
RECORDS MANAGEMENT OFFICER _ (i f * %n O. Telephone (516) 765 1801
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FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3206-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DAVID, ARTHUR AND MILDRED
Mailing Address 1 369 EASTWOOD ROAD
Mailing Address 2
City St Zip WOODMERE NY 11598-0000
Property Address 1 3825 STILLWATER AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6394
Tax Map No. section 137.00 block 1 lot 3.001
Cross Street TRACK AVNEUE
Issue Date: 5/19194 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,
OFFICE' OF THE TOWN CLERK c�V�FO(,��'
Town of Southold � CQ Application No. 2g6
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road � -'� $10.00 - Residential
P. 0. Box 1179 U' 10 `f ti •
$25.00 - Non-Residential
Southold, New York 11971 �0 •�`
Telephone -70
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 0,6,
Fee $ Db
DATE VICNI j C I0( Cltf-
OWNER NAME: Afl ,c,✓ � Io1fC C�J
OWNER MAILING ADDRESS: Boa. I.::ZGte-sIv'1OO IL:),_pck.--60
i����„►„ Ce , Ne..J (ork s qs
OWNER PROPERTY ADDRESS: e1pp-25- �7 �`i�•� ( ,�'�� }� [/1c�e.
ad-c1A05 Oe. 1 J eA.0 goy k 1 l G 3
on3— -3-7414-5-6-o
OWNER TELEPHONE NUMBER: — (03 �-
TAX MAP NO. : Section 1 3 7 Block 1 Lot 3, 1
CROSS STREET: 'T{cA jL P-44 ✓ 'L
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: A u� t. +( rQ 01 3
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: it_
/
Town Cle' 's Office
DATE:
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. SURVEY FOR • --
ARTHUR DAVID 8 „MILOREO OQ QTY l� ';- S. hf.4AfE
- MAP OF PROVE fas�
UBD/V/S/ON MAP FILED/N THE OFF/CE LOT NOS.
8 SCALE:-- ' =
(FTHE CLERK OFSUFFOLK COUNTY ON
EPT_ /8,/930 ASF/LEVO. 730• TOWN OF $OU THOLD - - - •NO.L 'I'_ •
YORK
SUFFOLK COUNTY, NEW =
a
it UNAUTHORIZED ALTERATION OR ADDITION TO THIS
SURVEY IS A VIOLATION OF SECTION 7209 OF THE ;` ��Y �L,F�NSUR
NEW YORK STATE EDUCATION LAW aTOAtrEQST
it COPIES OF THIS SURVEY NOT BEARINO''THE LAND fel Yom•\* i ,
SURVEYORS INKED SEAL OR EMBOSSED SEAL SHALL• , 'e;o-,N%r^
NOT BE CONSIDERED TO SEA VALID TRUE COPY. OF,k�
{,'. ,Ptd;•
THE P RSONEFOR WHOM THEE SURVEY IIS PREPARED,) 4 ,t`}',"x
THE PE 00VERK . +1,., „,a
AND ON HIS BEHALF TO THE TITLE COMPANY, if�,� ,
INSTTUTION LISTED;'' �:,-i4 ,
MENTAL AGENCY ANO LENDING TI E LENDING „,:::,•,:,::,,,
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`,•, , D,TO THE ASSIGNEES OFN ERAIlLt,.i ',.`,'; .i. ,'
HEREON AN RE NOT TRAN�F w>
INSTITUTION.GUARANTEES A c',, { ”
TUtI0NS OR UBSEQUENT , -S' �,
N. " TO ADDITIONAL INSTI S ;:_= 1+,':'.?,`:,,..,:
--`;'7,,,,"-' - OWNER'S FROM'PROPERTY LINfE$ `�f'e� S;�tis- ��.
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if OISTANC68 SHOWN HEREQN FORA SPECIFIC * ' 'f;�'i'•L
TO EXI TINE STRIICTUR TO®E USED TO EiTASLi'SN ''°
' PURPOSE',AND ARE NOT