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JUDITH T. TERRY �` Town Hall, 53095 Main Road
TOWN CLERK : =vrZ P.O. Box 1179
EP �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = BYO � Fax (516) 765-1823
MARRIAGE OFFICER '' �O ,�� Tel (516) 765-1801
RECORDS MANAGEMENT OFFICER — ®,l * t o�
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. 3152-R Residential X Non-Residential
Fee $ 100.00 New X Existing
Name Of Owner MADISON, GEORGE
Mailing Address 1 201-209 PARK AVENUE
Mailing Address 2
City St Zip ALBANY NY 12244-0000
Property Address 1 DUCK POND ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 83.00 block 4 lot 3.000
Cross Street OLIVIA LANE
Issue Date: 12/06/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3VFFIAA- '= --
Town of Southold �� - C'0 ' Application Nob-" 3
Judith T. Terry, Town Clerks , =4 y
Town Hall, 53095 Main Road • l $10.00 - Residential
P. O. Box 1179r.,-,7,!.7 „,�` $25.00 - Non-Residential
Southold, New York 11971 `0 € O� ��
Telephone = j Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
Fee $ • (L.
DATE M/7/9.-.3
•
OWNER NAME: e0iQ-G frfiffi/c50/11
6'
OWNER MAILING ADDRESS:/-20I ��SI.
ae4r7w /zzw • ;)
OWNER PROPERTY ADDRESS: n tee
_A 7/11 /1 35-
OWNER TELEPHONE NUMBER: /V�I9
•
TAX MAP NO. : Section O 3,00 Block 41 Lot 3,00
0
. CROSS STREET: ( 2. L4Jt&, d4Vl_t_-
TYPE
OF SYSTEM: ,_Septic Tank_-_ :_______ .New X Existing
Cesspool New X Existing
Residential l< 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.) •
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(aLH
.. Signature of Applicant •
SWUCi PAL TECHNOLOGY,BIC. .
1029 William Floyd Icy.
78
RECEIVED BY: P.O.1N.Y.x
- Shirley,N.Y.11967 - - ---
- . . Town Clerk's Office 516.2814 00
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NOTE .,.r T..;r
THE CONTRACTOR IS RES(10SBlLE FOR
O L / V/A LANECHECKING ALL DIMENSIONS SHOWN srttucruwu m Boyd Ser INC-
WORE teRocEt Dna WITH WORK. ANY 1029 Wdbra Floyd Pbry.
OISCRESH
PANCtES NOTED ALL BROUGHT P.O.Box 378
TO THE SURVEYOR'S ATTENTION .S N.Y.11967
IMMEDIATELY. - 516-281.4800
TAX DISTRICT X000 TAX SECTION 83 GRADES TO AS51/MEL) DATUM
SURVEYED 'Il/Na //. /091,3
TAX BLOCK 0 4• _ 03 ROADS- MAINTAINED BY: TOWN S..,.GaIltllflp,�
TAX LOTLOCATION SURVEY ION FNDI //
BLOCK LOTS 3 FINAL SURVEY _ ��stk. 0` NE�f''��l�rO
{ MAP OF Lt/OQO B/nlE /4--ms-A./Let/Q GUARANTEED TO: STi 'UC re.././e..4.4 Lc/-/AloL o 6 Y �d�;r ��n�:�E Z•V A,l�'•r0
AMCP,CA/✓ T/TLE /N5. CO. JEROME D'AMARO /1/1Ir! r. �.QL� :„..-4.I-..O
PROFESSIONAL ENGINE 1.LAND SURVEYORS CO t.��,tuc d_111, a1.
NYS LIC NO PEL 037209 L LS 049684 •; i (/' S d i o�
FILED MAP NO 8.2 9 FILED DEcEM BAR 4S 79@6-i ' 800 SUNRISE HIGHWAY •^,'a f l y T -...v.
I SITUATED AT. Town/ of -4 O '7WOLo.J QL,r Coof/TY,NY' - •i IT•R 1 �:
S SCALE 14'-30r WEST BABYLON,N Y 11704 .o �•'- 0".•9to; y?�
I1 TITLE NO.. DRAWN BY. NMiI CHECKED BY: (Stip 321 4488 SURVEY NO S930'9p q�•�, ig3z Np•0�;•��O``�
,Wnrauthonznd aIterahbn,or eddit.ont to lntt survey is a v,olet.on of section 7200 of the New York Stab Education Law Copies of this survey map not bearing the land Surveyor's inked nal or smbostad Seal shall not be considered to be■valid co Guaranteas or art./icauons.na.ated �Aft EBGBILL \\�VV�` '
�eredn frnall run only to ane person for whom the survey us prepaid,and on his behalf to the title company.governmental agency and lending institution hued fwaon.and to the issupnees of the Nnd.ng mstttutron Guarantees or artrfiat.ons erre not!renderable to add l Onal institutions /'/ (tttI1111I1 1\
1 or subsequent owners –Offsets are not to be used to establish Property lines