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1: JUDITH T.TERRY � � G'f'� Town Hall, 53095 Main Road
TOWN CLERK y P.O. Box 1179
nr Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER y4, o // Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ®.` #00. Telephone(516) 765-1800
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. 3692-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DOKA, DEBRA A.
Mailing Address 1 C/O MARTZ
Mailing Address 2 145 RYERSON AVENUE
City St Zip - MANORVILLE NY 11949-0000
Property Address 1 635 STANLEY ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-369-9103
Tax Map No. section 106.00 block 8 lot 111.000
Cross Street LUTHERS ROAD
Issue Date: 9/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r:
•• ii•
OFFICE QF THE TOWN CLERK �S�FFU(,/• •
Town of Southold ' ��% CSG Application No.Q3 G f f4
Judith T. Terry, Town Clerk ,;,,•; r.
Town Hall, 53095 Main Road -< $10.00 - Residential
tr
P. O. Box 1179 cn ;`- *► ` $25.00 - Non-Residential
Southold, New York 11971 O `. ''' �0��t`�
Telephone o.( , r5 d
iv f
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
q4/7/4/9
DATE
OWNER NAME:
eeQ `St\ SOk-Pt-
e•tjLi
OWNER MAILING ADDRESS: 1S `. 'n _Al ►I i� k, lig3-Z.
OWNER PROPERTY ADDRESS: eRSd1 Qi.)-z.
7
• OWNER TELEPHONE NUMBER: L. l ^ 11, 03
, Lk
TAX MAP NO. : Section ibb Block o8 Lot I o
CROSS STREET: k-Ci 5 R` 4)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential 0 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.)
l
moi i-• A
,
Signature of plic.,
RECEIVED BY: / ,
ow Clerk's Office
DATE: ?),2;21q-37�
, 1
I am familiar with the STANDARDS FOR APPROVAL
SCDHS Ref Na =R 10 - 97- 0002 AND CONSTRUCTION OF SUBSURFACE SEWAGE
dwe/%,,�9 s (ppb/�� wnte� DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES
1 and will abide by the conditions set forth therein and on the
s permit to construct.
spa -
STANLEY 55.$ -
ROAD
pc,bh6 water M s# . - . .
•
577 S. 87°II'00' E. !05.00'
i "4, 545'
kid I 1 •V
3 I ti tz. t
_ i , / 3S ST1 • - - V
1� zo r •
SURVEY OF
O
s_ ��� N LOT 12 „
�rporch wood I " SUNSET KNOLLS
• •
conc rr,��
` "J1968 MAP NO. 5023
to FILED JAN 5,
AT MA TTI TUCK
_ 29�. TOWN OF SOUTHOLD
3 - SUFFOLK COUNTY, N. Y
wood
°°" deck 1000 - 106 - 08 - 14
'L, Scale: 1" = 30'
Sept. 23, 1996
% - Dec. 27, 1996
• Feb. 27, 1997 (certified)
June 11 11997 ( certified revised J
- _Am 14, 49,91/(421..s se
- June 2-4, 199771 conc. foundation 1
• CERTIFIED T0, Aug. 8, 1997 ( final 1
4i 3 RURAL HOUSING
SERVG ,e� �l-Ati ;Ivy D-01.437. ;,.;•r f ggRvicEs
: CHICAGO TITLE INSUR
i^a a ��AUG 2 1 1991net No. /6-87 -0 COI/
LOT 11 a LOT 12 N LOT C) ,
O O i!K: vicse t,,,ezi E.T.A whit, ok-c9hc i1`i?itk3 QR M3 l have beats
(6 'Hii.-r tr u:`,t:.`;Ns DitImatmetA c4tar Lsr+ci 3$esd fogad to
L� a.:oit f 4174 ';.'-'vitas OP ,e7...Via.
—-- 7
lend„ --- ANY ALTERATION OR ADDITION TO THIS SURVEY ISA VIOLA TI�7N ''r�� 'A. E., �E�� NEP/)'
°Z s''� N. 88°4700' W. a"t cr�i F:�c=' 105:04.-----;-----
7o OF SECTION 7209 OF THE-NEW YORK STATE EDUCATION LAW,II :`t:c' ' 5►� tet `��ss T. MEr 0,p
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICA7tIONS or __Zr..,,
,f-
of-iv
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF ' •='•
/ SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR * = ,`' ?�';, .
o�wA; .,
Formerly KL�EINSCHM/DT WHOSE SIGNATURE APPEARS HEREON. `�P;,,::,.:
z��� Received
~' �.`�� i ..• 8 Suffolk iv d
MUSTEUADDITIONALLY TO COMPLY-WITH SAID LAW THE TERM ALTERED BY' r:A - L!
MUST BE USED BY ANY AND ALL SURVEYORS UTILIZING A COPY P 7 �, GYaSURV •.Y•i- ,:`".C.
unty
- The locations of wells and cesspools OF ANOTHER SURVEYOR'S MAP. TERMS SUCH AS 'INSPECTED'AND AUG 2 0 1997
BROUGHT-TO-DATE' ARE NOT IN COMPLIANCE WITH THE LAW. (5/ �'� fi'�1
shown hereon are from field observations P. 0. ='Xt
and or from data obtained from others. 1230 ,T�tTOf Health Services
= 20 33 Q. FT SOUTHOLD, N.Y. Il fide Of Wastewater Mgmt..
• ELEVATIONS ARE REFERENCED AREA , �7
TO AN ASSUMED DATUM.
96 — 272.