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JUDITH T.TERRY ,tx# =��� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
4,�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS F ,h e • Fax(516) 765-1823
MARRIAGE OFFICER `_ ✓ `� i
RECORDS MANAGEMENT OFFICER to/ Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER .v.0
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3711-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KARB, CHRISTOPHER AND EILEEN
Mailing Address 1 P. O. BOX 532
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 550 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5409
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Tax Map No. section 103.00 block 13 lot .5:002— l
Cross Street NORTH CROSS AND OLD PASTURE
Issue Date: 10/29/97 Judith T. Terry
Southold Town Clerk
•
(TOWN SEAL)
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OFFICEr�O`2 THE TOWN CLERK �cOF�ii-„7-
ows of Southold �� CQG Application No.37,/
Judith T. Terry, Town Clerk
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Town Hail, 53095 Main Road ; $10.00 - Residential
P. O. Box 1179 tr3 t'., ' ;' $25.00 - Non-Residential
Southold, New York 11971I
Telephone 'ffe( i►
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
fECEV D
APPLICATION
OCT 2 8 1997 for
SOLIthdd OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /CI 2- 719 37
OWNER NAME: C4-1RI576,ptk6R. G). 4 iI4GSA RARi
OWNER MAILING ADDRESS: -S-5-0 G� �G5 ���L K AVE- ,}
P A� K .5-32-- Co i C+I oC )s A5 1 (03s—
OWNER
(°f3sOWNER PROPERTY ADDRESS : ,6-5-c -a:c i �t='C� AJC=
C G H 00 - `f HI-3-S.-
OWNER TELEPHONE NUMBER: 7 31/- ,5*-iU9
TAX MAP NO. : Section /000 - /OZ /'Block ? Lot
CROSS STREET: OP4g 74( C p 5c..)
TYPE OF SYSTEM: Septic Tank / New 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.)
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Signature of Ap icant
RECEIVED BY:
Town Clerk's Office
DATE:
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CERTIFIED r0: SURVEY OF PROPERTY
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AMERICAN TITLE INSURANCE co. AT r
,fcw o�ti F�2�� ' TYLE- NO. 07- I11035
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1' '> ' ° PRUDENTIAL INSURANCE COMPANY
f $ it = �I MERICA , AND / OR TO�� 0� SOUTHOLD
� ;, , r1 NYS. LIC. N0. 49668 ITS SUCCESSORS AND ASSIGNS SUFFOLK COUNTY, N. Y.
`PE - . Qio- '*= = F. KAR®
TORS ENGINEERS P. C. CHRISTOPHER W. KARB , JR . _ _
'' EI LEEN 1000- 103-. 13 5. 2
(516) ` ;:� 0-�.
~' Preparedminimum
in accordance with the SCALE I��= 4 0
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P. O. EOX • � "
MAIN
1 o A 1987
standards for ri!ic surveys as established by J A N. 8'
the L.I.A.L.S. cHd as;roved and adopte -
' S 0 U T H C L D, N. Y. 1 1 9 7 f for such use by The New Ycrt• c+