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JUDITH T.TERRY 11,®�® *.4 Town Hall, 53095 Main Road
TOWN CLERK c P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ®�
MARRIAGE OFFICER ® i
�����, Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER . °` ��a'' 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. 3708-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KUNEN, BARBARA
Mailing Address 1 175 BURTIS PLACE
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 175 BURTIS PLACE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-6665
Tax Map No. section 67.00 block 4 lot 15.001
Cross Street FASLENDER AVENUE
Issue Date: 10/21/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK %� FRV.•'• ,may
Town of Southold �� CQG=� Application No. &7e9
Judith T. Terry, Town Clerk 6� *AN
Town Hall, 53095 Main Road a ° $10.00 - Residential
P. O. Box 1179 un $25.00 - Non-Residential
Southold, New York 11971
Telephone ��`�
pyo �o�;01
Yi
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ '
DATE /64///M--)
OWNER NAME: .D.�121F.,
OWNER MAILING ADDRESS: / 75- rarn PL.i c•-•E
OWNER PROPERTY ADDRESS : ` 5L'11—ull PL/a
OWNER TELEPHONE NUMBER: 7o6-----46 '
TAX MAP NO. : Section 7 D 0 Block Lot /.5'.1/
CROSS STREET: f S „.6r4 I,GW- /Se v _
TYPE OF SYSTEM: Septic Tank New V 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.)
4. 1 _ - S l , cv /2P,
Signature of Applicant
RECEIVED BY:
, Town Jerk's Office
DATE:
SCDHS. Ref. # RIO-96-0077
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1`DARK BROWN LOAM S.. ,91" ,�®9.® , { ;I
.*OWN LOAMY SAND 2.5'F -
PALE BROWN ED1UM / ,
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TO COARSE SAND I2' /
SANDY CLAY - ` -
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A RFA = 10, 137 $q. ft. f•- a
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CERTIFIED TO:
f P'
BARBARA KUNEN ,
SUR VE I OF
J
MAP _98 & 99 . 1
NO. 2
The locations of wells and cesspools shown hereon are from field IIIPE G ONIC SHORES ri
observations and or from data-obtained from others. FILED SEPTEMBER 15, 1930 pFILE NO. 654
The water supply and sewage disposal A T =- EC I SI C CL,
for thispies dance will conform '(
_
tothetandards of The Suffolk County TOWN OF SOUTHOLD
Department of Health Services. SUFFOLK COUNTY, N Y.
1000 — 67 — 04 — 14 & 15 _ i
. S Scale- 1” = 20' -
ELEVATIONS ARE REFERENCED -TO ASSUMED DA TQM. Nov. 1,
1990
June 24, 1997 ( FOUNDA TION I .-
Sept. 30, 1997 ( final ) ,of NEW y
ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION 'tQ i. MEr \-
-OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, S odd ��c``�
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS • ' 1 -r':'-- P \
HEREON ARE VALID FOR -THIS MAP AND COPIES THEREOF ONLY IF / :.3 1 r• .—, ' •rc
SAID MAP,OR COPIES BEAR.THE IMPRESSED SEAL OF THE SURVEYOR F �`-�'�-,..--
WHOSE
'"i
WHOSE SIGNATURE APPEARS'HEREON. - 4 -,l eh,���„Q ',. Lig. l,r. 496/8
ADDITIONALLY TO COMPLY WITH SAID LAW THE TERM'ALTERED BY' PECONIC ' i-7 P.C.
MUST-BE USED BY ANY-AND"ALL SURVEYORS UTILIZING A COPY (5f 6) 765 - 4.='� °. 490 �1
- OF ANOTHER SURVEYORS MAP: TERMS SUCH AS INSPECTED'AND P. O. BOX 9�'' F
,BROUGHT-TO- DATE'ARE NOT IN COMPLIANCE WITH THE LAW.
SEPTIC SYSTEM REVIsm•5/4�s2 -1230 TRA VEL"��srITE --
sEpric SYSTEM REVISED 77 11/92 SOUTHOLD, N.Y.