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Town Hall, 53095 Main Road
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P.O. Box 1179
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JUDITH T.TERRY - 0, /31•0 TELEPHONE
TOWN CLERK � (516) 765-1801
REGISTRAR 01-VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 846-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner HENNEMEIER, EDWARD & DOROTHY
Mailing Address 1 395 KOURO' S ROAD
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 395 KOURO' S ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-798-7249
Tax Map No. section 117. 00 block 6 lot 11. 001
Cross Street GRATHWOHL AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFDC,(
Town of Southold a7 ;, CQG• , Application No.
Judith T. Terry, Town Clerk * .�
Town Hall, 53095 Main Road 4• :L 7 Residential
P. O. Box 1179 cn =4y : Non-Residential
Southold, New York 11971 ,• 6®�'°°�`
Telephone _ 1 '
(516) 765-1801
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TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
CA
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE / --J()>
OWNER NAME: E a/ tb g 4J(�IP h( //e'/V4/ et/6
OWNER MAILING ADDRESS: 39 S O✓ i2o "s t O /1_0
,v ,50/Th LIC /V)/ //
OWNER PROPERTY ADDRESS: 51,g4—I
OWNER TELEPHONE-NUMBER: • 79 Z— 70) cr.9
TAX MAP NO. : Section 1/ 7 Block 6 Lot //•
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New )( Existing
Cesspool New X Existing
Residential ,x 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.)
?q-//A4 atealA-14::
Signature of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE:
TAX DISTRICT /0 ' TAX SECTION / / 7 TAX BLOCK Oa. TAX LOTS //•/ TITLE NO _ 07. //3-708
BLOCK. LOTS•
MAP OF E• S C /e /F3ED P R. 0 PERT Y.
FILED MAP NO. _ FILED SCALE / "1:"1: ZD/
SITUATED AT TOWN OF .50UTHOLO SUFFOLK CO., N•Y
S'T 2 9/0 NE4./ SUFFOLK
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GRADES TO • 5 S LJ DATUM 1TY�`l\5•;t1 %f/ s �c {�
ROADS MAINTAINED BY TOWN ,4. }� ®� NER, j JEROME D'AMARO " •t- e7
�� D'A O,} PROFESSIONAL ENGIVEER Et LAND SURVEYORS CO
.4444e/CA 7/TLE /A./.C. cc? �� O``�� M'9? et NYS LIC NO PEL 037209 Er LS 049684
GUARANTEED TO 0j ,4 O (
EDWA,PD REN^/EME/.P W a BOX 460M 1265 SUNRISE HWY
DORT/fEA ,S/ENNEME/R a :- x BAYSHORE, N Y 11706
Os ] n ? 9.:45 ; ,t �i (516) 968-8480
W , �. ,�'- �<< ,;-) a ' -587/.340
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SURVEYNO
• SURVEYEDOGTOE/2 Z /987
-- LOCATION SURVEY (ON FND) MA y /3 /988
• CHECKED BY n \ FINAL SURVEY AUG /9 /998
DRAWN BY �j�!J
Y
Unauthorr/ed alterations or addition to this survey is a violation of section 7209 of the New York State Education Law Copies of this survey map not bearing the land surveyors inked seal or embossed seal shall
x
o not be considered to be a valid copy Guarantees or certifications indicated hereon shall run only to the person for whom the survey is prepared,and on his behalf to the title company,governmental agency and
U lending institution listed hereon,and to the assignees of the lending institution Guarantees or certifications are not transferable to additional institutions or subsequent owners
t Offsets are not to be used to establish property lines HEAL TN DEPT. /A/FO. .SUPPL/E17 By BU/z 0.4c-rP - .QUG- /? /3B8
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