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JUDITH T.TERRY �� °" `, Town Hall,53095 Main Road
TOWN CLERK P.O.P.O.Box 1179
-, °} ,�� Southold,New York 11971
REGISTRAR
RF VITAL MARRIAGE OFFICER
%.` � ` ' ®� / Fax(516)765-1823
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. 3294-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KOHLER, MICHAEL AND CARMELA
Mailing Address 1 6700 NEW SUFFOLK AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 6700 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 115.00 block 15 lot 26.000
Cross Street DONNA DRIVE
Issue Date: 12/14/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COMA'
Town of Southold &,% . e4 Application No. 8 A F
Judith T. Terry, Town Clerk , y
Town Hall, 53095 Main Road < $10.00 - Residential c/
P. O. Box 1179 cn •• i ; $25.00 - Non-Residential
Southold, New York 11971 O` ��$
Telephone _o,1 * %k0"
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit .No.
Fee $ •
•
. DATE
OWNER NAME: i l iG-h/i,4&J- b .....,q- ( ot1 C.E.. 6 ..,. 5 2,„-.
).
OWNER MAILING ADDRESS: 67ct) ,cue) 3�FFo1-le- 4
/°itA-71rTk/� ,e)t' //fsry
OWNER PROPERTY ADDRESS: 6749 Ju) 1.,i' LLK. Aa
)4/4---T-T,-;t-te*___ /toy. i /eke/
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section // ,5.- Block / . Lot Z6
CROSS STREET: -170Al 0/1 2.-e.IX
TYPE OF SYSTEM: Septic Tank \Z New Existing
r
Cesspool New ,L 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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r)/i,e__;, ,
'° r / teAll.
Sig - . '"i' o Applicant
7e_c4ti/-1,- airwo
/.-"A-Ay---pC_Q_____ -
RECEIVED BY: /V/ /1
Town Clerk's Office
DATE: / 02 —/a —Q1 '
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• S/R✓E'yED" /..0!2 /i�%c/-/.Q L 0 CARMEL.4-•, /<- e.,',-/.7/4.-'--,7--
, •, , •• T •-' 6.•c•r•/YI. "o. /000-//5-/5=26 " •r
pRopERTy LOCATED A7 MRTT/TucK •
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/✓IAP, of DEEP Ala E CREEK' 57A7E5 �� st
/or' 22 - , �'"V .
A:-/Lo " 'c�pF NEW Mo'�
�gn/uARy 28, /965: F/LE A/o. 4256 C,5(/ �r %• BA, ¢
TOWN Of 6Oc/TNoLD '4-.A.6 or-
yam, �` /�
✓c/Ffe,Lk Co uni r y NEW yoRK L R w !/
AREA - 2/, 76 7 .5F `��' LJ- ...dr.- /4,4„.7.,,,)'�'f/J �X,S /,� r At i {�
6SCALE'/"elip' Brp0„E
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Unauthorized alteration or addition to this sunev is a violation
N ��`•ei, LAND 9v
of Section 7209 of the New York State Education I aw n
Copies of this survey map not hearing the Land Surveyor's inked ng /0
seal or embossed seal shall not be considered in he a valid true \ 4� �"'�L
copy ' Q�
, INOtO
Guarantees or certifications indicated hereon shall run only to tv i I '`0n •
the person for whom the survey is prepared and on his behalf to 107• b� N -
the title company,governmental agents and lending institution br ,vEw
listed hereon, and to the assignees of the lending institution 22 s�oow - V ^”1 _ V ;!
Guarantees or certmcauons are not transterablc in additional / F6,vc �/ r,?
Institutions or subsequent owners L�T ✓ 9•w a F
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