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ELIZABETH A.NEVILLE �°� �T Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
ka2 1 ,mt Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
® kt. IV 0 Fax (516) 765-1823
MARRIAGE OFFICER : � ' �1
RECORDS MANAGEMENT OFFICER 01 .0410� Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER - •s
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3784-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner LUTKOWSKI, ANDREW K.
Mailing Address 1 380 PRIVATE ROAD #27
Mailing Address 2 WATERVIEW DRIVE
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 380 PRIVATE ROAD #27
Property Address 2 WATERVIEW DRIVE
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4010
Tax Map No. section 78.00 block 7 lot 32.002
Cross Street BAYV I EW ROAD
Issue Date: 4/23/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
' "' '
OFFICE OF THE TOWN CLERK ��FO7 " '
Town of Southold , �� �CQ�t Application No�
Judith T. Terry, Town Clerk 11
Town Hall 53095 Main Road g $10.00 - Residential
P. O. Box 1179 V tri -•
`' $25.00 - Non-Residential
Southold, New York' 11971 "$
'0 40".
Telephone .(
(516) 765-1801
. TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for _
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL -
Operation Permit No.
Fee $ • '
• DATE ' 0//fg
OWNER NAME: 4,'bpec,j I LL leoc,c,JS iCi
OWNER MAILING ADDRESS: 3A) put 2b
OWNER PROPERTY ADDRESS: 04/3-37e;:' -
OWNER TELEPHONE NUMBER: 77S- iia / O
TAX MAP NO. : Section 7,j7, Block 7 Lot 32 , 2--
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New 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.)
Signature of Applicant
RECEIVED BY: /4/XL...,L,--/r("0"
° Town Clerk's ice
DATE: -
l , SEPTIC AREA-; 5 SUFFOLK CO HEALTH DEPT APPROVAL
/
\ T' /"/2 H 5 NO 210-95-0060
MAP Or _PROPE12TY _ (RES)
CESSPOOLS • .
SURVEYED F02 1 \
ds \ i I I STATEMENT OF INTENT
I I ! ' 35' THE WATER SUPPLY AND SEWAGE DISPOSAL
•
f/ i L/+i'•--�'`J?C1 '•i-1 /rL. F�-t L-.'I i t t t `\'N ' - I SYSTEMS FOR THIS RESIDENCE WILL
J•v — ------^---- -• - - - -- 564554,30E , U. ! CONFORM TO THE STANDARDS OF THE
i O
Q� AT �? \ ,... t00 0 < I SUFFOLK CO DEPT OF HEALTH SERVICES
r n .1 'k 1 a , (5)
` 0U i NO LI. \�, ? q9q �—,—- -, �. I APPLICANT
J� • A[ 70V/ty OF SrJl1THCLi: U`f; �� `. I ,/ _ 74' _
/ A�+ .,5;,„03. p� -----•-------------.--- •-�--_- L7 l% I HOUSE SUFFOLK COUNTY DEPT OF HEALTF
T - .r 40.6, I -L /( SERVICES - FOR APPROVAL FOF
s� 4p- / - BUILD(IJG
i -v✓ELL CONSTRUCTION ONLY
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ENVELOPE - • r I DATE
�o - \�.�- - `ro N. , - 15.0 i H S REF NO 12'0-95-Q080
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f /!j/{, \,� rGQ ,� Ji ,1 r ' _ I APPROVED
\ C 1 W 4TF -,• / 4r / i l L>OPC-Q FLO012 ~ I 50 -T- �� I I
\\�O O,� �0,1D 33f .� the' r ,�\Q� // OV�eONGaAQQ� I 1 0 LI SUFFOLK CO TAX MAP DESIGNATION.
�� -„s L'tA�O� (�r �'� I --- -�j-- S— o �0lY-J DIST SECT BLOCK PCL
�� - 55,7- N. N - 1000 C78 32 2
. \ � N °°ed/) '•`�� / ELECT. I - _F ' .4
i 5 lyz•ST. --- N�
ter. TN J fx D¢�� ZI y r2. �t / - • -_ L--ISO- i iOWNERS ADDRESS
o N _
DEPARTMENT OF HEALTH t 20 g� e] HO. u, `� TO WELL I 380 PLZIVAT$ SCA Z"!
SUFFOLK COLIN - ' Ib ) ,y
ii U j enaTH r' 3 oto • I t�lAi�1<V:cW Df2;1J;:
•
APPROVAL OR CONSTRUCTED WORN3 I.ZR p - - - - r � .A�" w9�� �O
ASING FAMILYRESIDENCz -I 7 -i SOU'SF '1Li , N • ii l r i
Dee APR 0 8 1998 Qlp,95-OOBo •
_ � 'a 2z
IL¢. eLNo. i o 1-- so'- -� ',°,r-- �1/ y�Pt'� 4 'Sb�s I C7Ei=T(o5 iClOj
0 1 F
The sewage dlspesal and water imply thcilltles at ibis Ln:woa nasi pan. o ! ��' ( j_ . DEED• L 2341 P 4(REF.)
Inspected and/or citified by this Ideparcnent or ataer agendas end iol nd t� 1
p ROOMS. I .i �� Recervetl TEST HOLE STAMP
bo satisfactory FOR NCI F , Z \ Suffolk County "
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c1
St hot A Costa,P.E.Chief .. N o .i
• /! P �� • : I •I ,, waterM9rnt
tttt�z ,,j� m LOAMY Sou()•\ yr ; < 7^ ``*,T,'"
�x - _
" O O. Crp COLYOURS FROM_SUFF CA.D.P_W AERIAL I ---— a1 i,
\' SCALE SQ.I R << SUQVBY DJ1ZtF MEIN SEA LEVEL NGVD. PALE Btl^WL! ti
PQEMLSES IN FLOOD ZONE C.
FINE 7) .__ ::�,
C't=MONL'MENT ,/O 10 c-'o. -- - :AARSESAUD C.""
-`PIPE � , p p \ - :r,--;_- •-- L
_ . ---13-1 1 -'degi�a- C-.
7 LAND -• •__ •"_ p �C� GL ACL'�!.iTEEC; �_:t-IiLAi:r T_I1L5 It•1SUR_F\UCE WATER IN v ��`�.LEw'9y0 Si.
A OF GL•ANITLNtgIy - ' -----_�iT. Ih CO #TO SUFFOLK L"Jt}N TY NATIONAL BAt•lt("' PALE BROWN Q O O
L-------_—----'-•'----- FINE l0 t
3 ®i u -ro a =3 MAP AMENDED MAY is 1995 r COARE'tu . :51,
t s
_ A 5U RV E`( _D AP 2.17 j191,-5- * w!-�
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_ -�- ADT Pei VATS 40I D N O FINAL FEB. I l, 1998 8Y i2. ✓..-. T- /---- '>+%i4:..
r• N• 0l OO w �_'- .N ANTI-TONY W. LEWANOOYl51GI,L 5. LICENSED LAND SURVEYORS 17' E • ! :'
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