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ELIZABETH A. NEVILLE•
X41 4 Gy i Town Hall, 53095 Main Road
TOWN CLERK o P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax Iji �����, Fax(631) 765 6145
RECORDS MANAGEMENT OFFICER . �Qliii �a0�1� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ��9 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4191-R Residential x Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner MOTHERWAY, NICHOLAS
Mailing Address 1 193 WILLIAMS WAY SOUTH
Mailing Address 2
City St Zip BAITING HOLLOW NY 11933-0000
Property Address 1 940 LAUREL COURT
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 631-793-9950
Tax Map No. section 125.00 block 4 lot 24.001
Cross Street ROUTE 25
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Issue Date: 2/12/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
IIIOI.
OFFICE OF THE TOWN CLERK �` /97
TOWN OF SOUTHOLD `�S�FFUIK`D
Application No. `
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 ���! $25.00 - Non-Residential
Telephone 0 * NO
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Of-29— a3
OWNER NAME: /nOrikkk✓/ J the
OWNER MAILING ADDRESS: /93 GvjL/��grn � 1 �‘„ L
097,77V 4L(/)/A_/ ,✓ J//93_3
OWNER PROPERTY ADDRESS: 90 L4ig_c.c_ C v
Y //95/,
OWNER TELEPHONE NUMBER: ,j/- ?9f- 9'S',3-0 0
TAX MAP NO. : Section /2.5- Block 7 Lot 2y,, un
CROSS STREET: AJlT 2.5
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New )C 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.)
41 - �r
Signature of Applicant
RECEIVED BY: •
Town Clerk's Office
DATE:
FEB-03-03 11 :08 AM SHARP CONSTRUCTION CORP. 631 728 7962 P. 03
Suffolk County Department of Health Services
Office of Water Management
Suffolk County Center
Riverhead, New York 11901
631-852.2100
CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER
Health Depart Reference# #K10 - 01-0 2.5'67
Suffolk Tax Map# Dist: Sect(s) I ZS Blk q Lot 2`i,001
Project Name and Address: • l L 1 L/' £.L Li, 1-
Subdivision
Subdivision Name and Lot# y , L L i
Applicant's Name: t CR: ,120
Description of system Installed:
Septic Tank
Volume (gallons) 10°0
Shape: Rectangular (cd'Cylindrical ( )
Name of Precast Manufacturer: d^
Leaching Pools
Number of pools
Diameter and Depth: W X II
Name of Precast Manufacturer b 4r4tt
Other:
MEASUREMENTS:
I r r J )
-'1;N\4
I hereby certify that the subsurface sewage disposal system, described herein, has been
installed by me in accordance with the approved plans and standards of the Suffolk
County Department of Health Serves, and is operational.
Installer Signature: MINIM Date:
Z �J /o3
MINIM
Print Name/Compa y : SUFFOLK XCAVTING CORP. Phone: 631-878-4467
Consumer Affairs License Number : 14,081 EXP. 2003 LW 252 EXP. 2004
This certification shall not be used in lieu of inspections required by personnel of the department and may be
duplicated on company letter bead,provided It contains above information.