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JUDITH T.TERRY ® ,'A� Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
8111 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 0 V4-. �1 Fax(516)765-1823
MARRIAGE OFFICER � �®
RECORDS MANAGEMENT OFFICER i U:1Efigjg 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. 3377-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner HENNESSEY, THOMAS AND DONNA
Mailing Address 1 P. O. BOX 450
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 OLD SADDLE LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-4271
Tax Map No. section 95.00 block 4 lot 18.010
Cross Street GOLD SPUR
Issue Date: 8124/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK '%IFEV(
Town of Southold �� Application No. 3 3 7
Judith T. Terry, Town Clerk. ��
Town Hall, 53095 Main Road a $10.00 - Residential'
esidential�
•✓
P. O. Box 1179 u' M .
:) $25.00 - Non-Residential -
Southold, New York 11971 O`
Telephone
(516) 765-1801 _ O! �
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1 31,l'
Fee $ 10.0
DATE 24 3 lb-
OWNER
NAME: -motyyjc5 and otnnoc ene5 e
OWNER MAILING ADDRESS: F.D. 801 4.5o
CA hb u.e.-, N. 1 11 q,35.
OWNER "PROPERTY ADDRESS: � 50161(31(e.
Cul--ch u5 o,e1 935
OWNER TELEPHONE NUMBER: C510 M- 4-2 7j
TAX MAP NO. : Section 615, cid Block 4 Lot 1 9 .01 0
CROSS STREET: lS OIc sur
TYPE OF SYSTEM: Septic Tank y• New x Existing
Cesspool New - / Existing
Residential 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.)
fir,,/'
/�'/�t�,04.0
Signature of Applicant -
RECEIVED BY:
R nClerk's Office
DATE: AUG 2 4 1995
Iowa Clerk Saadi
:WELL l_ _ _ • .. _ " -/ • _ ' 'SUFFOLK.Co:HEALTH
MP -. OFrY. P .? :a R e"
_ :
. ' r ZiI . te ' �� . � 1IIt F:"' NO�
LY
•6; -S GREs,) ! (3r1.fi�X -- DONAP\ 11 i
f"FS EE YEARS FROM ®ATE, A
F ( _
STATEMENT OF INTENT— —
'�----� --,1� / - + - ' �:' . I •..•AT.-`- - - _ , THE WATER SUPPLY AND SEWAGE DISPOSAL'
! - I cUl CWD6UC - SYSTEMS _, FOR THIS RESIDENCE WILL'
(,
TOCONFORM -TO' THE STANDARDS OF THE
\ \& J O! S t1T4'IC�trp 11t�1' SUFFOLK CO •DEPT. OF HEALTH SERVICES.
• 1 GGLD SPUR S11 ET - -yg43 . - SO': (S) APPLICANT
, ii/> EDGE aP.6u�tcraP
IZESCEVED COR • .k1,59`42 35.E. / ..-'- 177,83 .-1 • SUFFOLK COUNTY DEPT. OF HEALTH
POSSIBLEFUTURE h14.' IVU ��— SERVICES - FOR APPROVAL FOR
EASE M EMT
' HIGHWAY DPDICATIOI4 =� \ [:POOL -,yam
O ' ' CONSTRUCTION ONLY
`` _ $5, ,,I00.-----"'"--
'.
;100 -- "' I 1
�t �1, \5�t -- - -- ---- 50 ,' ,. ,, w,; - DATE.
1 r (J.�L �n PtZQPM/Fil h— W' a�� tr, ,, .
H.S.REF.-NO.. I 5-007I1
LSA . 0 N APPRO , '
MIN UaLLL - -- -, - - i _ -s ... . ..:.i _
DEPTIa loc �S9\ -� I
' 3E _'OLi= -� I
' SUFFOLK CO,TAX MAP s- SIGNATION: . s
11' .r0 (AIAT �. ®I • , .: .-\yo.-1-1 - - DIST: SECT. 'BLOCK PCL. ._
;,5\V\C'�'T'} ,`• i . ` \ �, R0' - 1 • . in 1 / ' - .i000.. - \ '095 4 18,10
t�IP � YooL t.--- t- Ol 1 1, OWNERS ADDRESS:
i 4 frillt t
` / I I i___ 71E:
HE ER SUPPLY AND SEWAGE Dt$o4S
��\ 8 .i . S T S FOR THIS RES tDENCE V I LL coNFceM LOCUST„ROAD •
1 . \Q(..).1 P27PSFPTK/ y. –i 1 STANDARDS OF THE SUFFV•K " P b )(-�
• `r, Y EP T OF HEALTH SF.R11ICES. y IX4757-t2#i/E ..,N.Y_11792
tr : l 2oT ELL s l , AR ���I
5a5�" sooy / Erna j , iiz.,-,/ A� ,TT.,L.929--354- -.- . ,
%:-ASSUMEDfEI 1 A `i A���'..x . +" %l- 7,
S :.&2� FOR O tU)4 / \q ug i7 ---,ca - DEED: L. _ -P. .
,-'' .� / �� 1 a • -10.%s.:4--c,5§2-5.t TEST HOLE VAMP
d U1
F
emei.t�.�v
S��, / \ / s o� Dtm061 1!- T TH.'S3 - lt,nal/homed
'�tlo "‘ a 'JN ' ,lPipeFIL$t7 MAP. lea ,zggwf me Newy«lb sima
r !� / 'l 0- :ii �a HUB -TOPSOIL Gop,es of d,.s survey maO not bearNO
1\g ��sl –�/ �\� O -y'. �� j— +' ---
%.5‘ I embossed soca snail not beatw+sNsrod
T Q7 01 lobe a vend tnre cow
Indicated hereon shad run
/ Guarantees vis
\ // • -LOAM only to the Person tot wham the survey
\ t / fq Co 4 \ _.CLAY PraPa ad ams h�behalf to the
-vemmental egeray and
0 lee damns to S-
• \/ lendn9 uhst•M on irsted hereon end
/1 to the assignees of the lending thstf-
G , � V % Urban Guarantees are not moterebl_
��/ Q `,(` --__.--_�5' al nstmutans of eubsaGrard
'aeslD�Nce) �1CI Q- LYNCH HOMES INC. to
Py/ars
�q0�b '/ a`�,� COUNTY ROAD 39A SEAL
; c% 'qq' / SOUTHAMPTON, Y 11968 sAND.e o::::V1...: 1:.,W
�I. ti -
,a ' AP : ..,9' t ! GRAVEL i��:1„4„,„.,�' r h � .(v NOTE: m P �UFLVI 'rr3 APQIL 19 Ig�i t . G< •
LOT NQI S`REFER,IU MAP OF OiZ-E„G_OIJ - ---- •-- :* rs p VIEW. ST'S.aFILBD 111 T1d1eUF!`.G0. „- :. 0,
' -" -" RODE ICK VAN T L.P. ,4j " CLERK'S OFFICE A5 MAp t40.62dLI. ! . ✓. , l--- "....4.,6„:
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' -- LICENSED LAND SURVEYORS 14 --4 Eo LAND 25_\30,
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Laty1 GREENPORT NEW YORK
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