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JUDITH T.TERRYI��=1�® 7;4 Town Hall, 53095 Main Road
TOWN CLERK ; Z P.O. Box 1179
es• rry Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER � . •g Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER =�®.( p �e�®611 Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER .� ,.�el
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3621-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner MALONE
Mailing Address 1 C/O ELE DEVELOPMENT CORP.
Mailing Address 2 P. O. BOX 1143
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2210 GABRIELLA COURT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 108.00 block 4 lot 7.048
Cross Street ELIJAH'S LANE
Issue Date: 14/30/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
Loo 2 324
•
tFFICE OF THE TOWN CLERK
Town of Southold � CQG:, Application No. Mr
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road -� $10.00 - Residential /
P. O. Box 1179 u' ;' $25.00 - Non-Residential
Southold, New York 11971 O ' ���'`,
Telephone e.( * ��
(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: 1\-A -a..] dh
OWNER MAILING ADDRESS: '7-2-I O al �bVZ, I Q C_,+
M a+--ac-F- 1'4 I IJ•`( I let SZ
OWNER PROPERTY ADDRESS: tH'm
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section I OS Block 4 Lot 1 •
CROSS STREET: alt ft- 1'1 ' Ft-,e
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.)
natur- . ' Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
1
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�p _ e �+e1, Z. �� "ELIJAAS LANE ESTATES, SECT. .
/ E. � cis FLED OCT 8, 1996 FILE NO. 99
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�\ , ., \ z 3 S . 25 SUFFOLK COUNTY, N. Y.
���. 62. 1000 — 108- 04 —P/07.1 I
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ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION / am familiar with /he STANDARDS FOR APPROVAL The locations of wells and cesspools ..
OF SECTION 7209 OF THE NEVI YORK STATE EDUCATION LAN, - AND CONSTRUCTION OF SUBSURFACE SEWAGE shown hereon are from field observo/ions
EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTFICA17ON5
HEREON ARE VALID FOR T7•d 9-SL AND COPIES THEREOF ONLY IF DISPOSAL SYSTEMS FOR SINGLE FAMILY RES/DEVICES and or from deo abloined from others.
!�. SAID MAP OR COPIES BEAR THE&PRESSED SEAL OF THE SURVEYOR and will abide by the conditions set forth /herein and on the
M WHOSE SIGNATURE APPEARS HEREON. permit to conslrucl. PECONIC 76S EYN
ORS,
al ADDITIONALLY TO COMPLY $77}7 SAC LAW THE TERM ALTERED Br (5/61 BO - 5020
909
MIST BE USED BY ANY A/C ALL SURVEYORS UTILIZING A COPY P. O. BOX VEL
OF ANOTHER SURVEYOR'S MNP. TERMS SUZY AS •WSPECTED'ANO ELEVATIONS ARE REFERQVCED /230 TRAVELER ST.
'BROUGHT-TO-DATE'ARE NOT PI COMPLIANCE WITH THE LAW. TO'AN ASSUMED DA nim SOUTHOLD, N.Y. /I,