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JUDITH T.TERRY �/� , `AI; � , •% Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
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Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ` Fax (516) 765-1823
MARRIAGE OFFICER 4 4z).•••
RECORDS MANAGEMENT OFFICER ®� � /// 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. 3623-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner JACKSON, LISA
Mailing Address 1 C/O ELE DEVELOPMENT CORP.
Mailing Address 2 P. O. BOX 1143
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2015 GABRIELLA COURT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 108.00 block 4 lot 7.053
Cross Street ELIJAH'S LANE
Issue Date: 4/30/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •''. _ 36 (13
OFFICE OF THE TOWN CLERK cOFO(,lr
Town of Southold ,. e4N, Application NoalliM
Judith T. Terry, Town Clerk ��Di,±' y
Town Hall, 53095 Main Road tx _ $10.00 - Residential
P. O. Box 1179 tl ;'.;;y ;' $25.00 - Non-Residential
Southold, New York 11971
Telephone *0"")§t-
(516)
1(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $ •
ff
DATE "11-T11 191
OWNER NAME: L I s � �(2)�
OWNER MAILING ADDRESS: S e- I
Z 7 -FLA C )< � N. T 11 (4, 5-2-
OWNER
I (4, 5Z.OWNER PROPERTY ADDRESS: S R11-1 C-.
OWNER TELEPHONE NUMBER :
TAX MAP NO. : Section i C:) .6 Block 14 Lot —1 +�3
CROSS STREET: El k
TYPE OF SYSTEM: Septic Tank NewExisting
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.)
/7c6nat of ppA licant
RECEIVED BY:
Town Clerk's Office
DATE:
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-;-...c., ,., "ELIJAHS LANE ES TA TES SECT 3
F/LED OCT 8, 1996 NO.� 9912
-.--...,:.-.7,.:x.,wi . t Ap ,r,„. �� �-�� �.�_ AT n�A TTITUCK
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0 TOWN OF SOUTHOLD
' s� G SUFFOLK COUNTY, NY.
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s Scale: 1" - 49'
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Dec. 4 1996
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' t 9UFrouc colN°IY DRPAR3i�TT OF ,Tx�T�Rvicts
_" Tt APPROVAL �f�
O + i3C�YYt1K FOR A
SOKILE FAMILY RISMINI ONLY
2i DATE :-. \--7\''.\-1 FS REF.NO. 1 fl -�l 7 . 00%(0
_
:4,.. - 2
(, F APPROVED ED \ \ \v'. \2i v�l �`C,
—: r ` r' FOR bUM OF
v4 G E FIRES THREE YEARS FROM DATE OF APPROVAL
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Min . i .1 C
_- am familiar with the STANDARDS FOR APPROVAL ��J s9e�6 A
CONSTRUCTION OF SUBSURFACE SEWAGE The locations of wells and cesspools .�� S
OSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES shown hereon ore from field observe/ions 1
will abide by the conditions set forth herein and on the / i .,,, N.Y.S. LIC. NO. 496/8
and °r /rom data obtained from others.