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JUDITH T. TERRY " Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
���' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1805-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KELSCH, PAUL
Mailing Address 1 405 WENDY DRIVE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 405 WENDY DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4398
Tax Map No. section 127.00 block 8 lot 19.000
Cross Street PECONIC BAY BOULEVARD
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cl\VFair
Town of Southold CQ ' Application No. /'fO
Judith T. Terry, Town Clerk f �'
Town Hall, 53095 Main Road ,4 $10.00 - Residential
P. O. Box 1179 cry '� � $25.00 - Non-Residential
Southold, New York 11971 O ®
Telephone 4 L' Y►� .°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /1- 11-9/1
OWNER NAME: 41144/�✓//7
OWNER MAILING ADDRESS: // ,' 1./evt-0/ O3 '
1-c te 4 Y /(914 .
OWNER PROPERTY ADDRESS: S�vvtr✓ .a...1227ve
OWNER TELEPHONE NUMBER: 37,
TAX MAP NO. : Section /2 7 Block Lot l5•
CROSS STREET: Peiowtc.- ACU lemon-ted
TYPE OF SYSTEM: Septic Tank X --- _New Existing X
" Cesspool New Existing X.
Residential 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.)
.44/(afr'L
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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0059�, PE CONI VAR.* RE.auE.' TE.D VA2IAAIGE PI TAIJGE
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SURVEY FOR
PAUL KELSCH
JUNE 9,1986
AT LAUREL DATE' FEB. 13, 1984 '
, is`-`-<.)a ,, ,j' ,.",r `r'.ri..:0 ;,,, _; 1u��0,
TOWN OF SJUTHOLSCALE:
D
SUFFOLK COUNTY, NEW YORK NO. 84- 47
t�'' ` _ 'r+:� J:T, Nu ___ _ _ _ __ '
y� 1UNAUTHOR1ZEC 'ALTERATION OR ADDITION TO THIS GUARANTEED TO: •
SURVEY IS A VIOLATION OF SECTION 7209 OF THE » ^-^
NEW YORK STATE EDUCATION LAW I; oF- *COPIES OF THIS SURVEY NOT BEARG THE LANDSURVEYORS INKED SEAL OR EMBOSSED SEAL SHALLNOT BE CONSIDERED TO BE A VALID TRUE COPY*GUARANTEES INDICATED HEREON SHALL-RUN ONLY TOTHE PERSON FOR WHOM THE SURVEY IS PREPAREDHEALTH DEPARTMENT—DATA FOR APPROVAL TO CONSTRUCT AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERN- � �
* NEAREST WATER MAIN—MI.± *SOURCE OF WATER: PRIVATE✓PUBLIC_ MENTAL AGENCY AND LENDING INSTITUTION LISTED N �' G)
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*SUFF CO. TAX MAP DIST#0.0 SECTION 227 BLOCK_@_LOT-lam- HEREON,AND TO THE ASSIGNEES OF THE LENDING L
*THERE ARE NO DWELLINGS WITHIN 100 FEET OF THIS PROPERTY INSTITUTION. GUARANTEES ARE NOT TRANSFERABLETO ADDITIONAL INSTITUTIONS OR SUBSEQUENT rt" �''
OTHER THAN THOSE SHOWN HEREON. OWNERS .}
*THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENCE *DISTANCES SHOWN HEREON FROM PROPERTY LINES 1\\,0 • dg�WILL CONFORM TO THE STANDARDS OF THE SUFFOLK COUNTY DEPARTMENT TO EXISTING STRUCTURES ARE FOR A SPECIFIC `
OF HEALTH SERVICES. PURPOSE AND ;,RE NOT TO BE USED TO ESTABLISH �6,.a.':° , IC �'
APPLICANT' PROPERTY LINES OR FOR THE ERECTION OF FENCES ��
ADDRESS 400 OSTRANDER AVENUE
TELYOUNG YOUNG RIVERHEAD, NEW YORK
N.MONUMENT
1 ALDEN W.YOUNG,PROFESSIONAL ENGINEER
,
- ' fiND LAND SURVEYOR N.Y.S.LICENSE NO.12845
4 '! HOWARD W.YOUNG, LAND SURVEYOR
*THE LOCATION OF WELL(W),SEPTIC TANKIST)B CESSPOOLS(CP)SHOWN HEREON N.Y.S.LICENSE NO.45893
ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS -
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