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ELIZABETH A.NEVILLE0/4' #* Q Town Hall, 53095 Main Road
TOWN CLERK * 4, P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �� ► 4 �1,, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER i Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER -IitCOUtiri, I, southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4299-R Residential X Non-Residential
Fee $ 25.00 New X Existing
Name Of Owner BEDELL NORTH FORK LLC
Mailing Address 1 32225 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 32225 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 631-000-0000
Tax Map No. section 97.00 block 1 lot 2.501
Cross Street BRIDGE LANE
Issue Date: 12/05/05 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
)
ELIZABETH A.NEVIT LE
2 Town Hall,58095 Main Road
TOWN CLERK 2P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER = 1Y ,�. Fax(881)785-6145
RECORDS MANAGEMENT OFFICER - •� AV".
" Telephone(681)765-1800
FREEDOM OF INFORMATION OFFICER "- , ,,,.•'' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @$25 )( Application No. `-'1 dl"tQ
Permit No.
Owner Name NJ2 t"r-f fU
Owner Mailing Address 32-2.2-4-i- 1'4 k( V j2.o i
C -u IL/1. l i93(
Owner Property Address r ,.,,�;
Owner Telephone No.
Tax Map No: Section 9 7 Block / Lot 02 S 0 /
�i �s
Cross Street G
Please check each that applies: New Construction
Alteration to Existing System
Residential Non-Residential ti
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may sucopy of survey with SCHD approval.)
Signature of Applicant Date
Received by:
TKF Excavating&Demolition,Ltd.
4 Pepperidge Lane
East Moriches,NY 11940
631-878-2700 Phone/Fax'
CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER
Health Department Reference Number: C I - 61 - 061 .3,
Suffolk Tax Map#: Dist: 1 0 QSect(s) ''7 Blk(s) I Lot(s) "�' . I
Project Name or Address: 00 Sect(s)
P(1 e I(ars , C td j u
Subdivision Name&Lot#
Applicant's Name: « rj 42,1" OD n S`4--rt
Description of System Installed: 3e pf t?1 1'
S e,vn
Septic Tank 1r'
Volume(gallons) C)
Shape: ( )Rectangular m cal
fiLeaName of Precast Manufacturer: j 0,07 o n d Pre Q St--
Leaching
ching Pools
Number of Pools
Diameter&Depth 1 . 5�
Name of Precast Manufacturer: tQ mond Pre ea St-
-o fi
Other:
Attach or sketch below the measureme ' : ' I uilding co • to the acce co -rs of
disposal system. , o,,4 - - _ _ _
. 4,fir,
11,11
2.
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 Services;
and is operational. 410
Installer Signature: Date w 70 Id'S"
Print Name/Company: • • . ,_ Phone(931 -$7 Y-ai)oO
Consumer Affairs License Number: 3 fl( L k j