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HomeMy WebLinkAboutGustavson , O �,�'••I Town Hall, 53095 Main Road 4zzy P.O. Box 1179 ��: l� Southold, New York 11971 JUDITH T.TERRYTELEPHONE TOWN CLERK (516)765-1801 REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 67-N Residential Non-Residential X Fee $ 25.00 Septic Cesspool X New X Existing Name Of Owner GUSTAVSON, TROY AND JOAN Mailing Address 1 P.O. BOX 247 Mailing Address 2 City St Zip ORIENT, NY 11957-0000 Property Address 1 7780 MAIN ROAD Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-298-3200 Tax Map No. section 122. 00 block 6 lot 29 .100 Cross Street BRAY AVENUE Date Of Last Pump Out 0/00/00 Issue Date.: 5/16/88 Judith T. Terry Southold Town Clerk (TOWN SEAL) ti --- -A OFFICE OF THE TOWN CLERK c0FO(A'()Q .:" ��,e(' Town of Southold �� r-. ' , Application (Y0. Judith T. Terry, Town Clerk -"4` Town Hall, 53095 Main Road � Residential , P. O. Box 1179 51 ° aris* Non-Residential Southold, New York 11971 Telephone to (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit Nod/ 4.°6, 7 Fee $ • DATE WM � � 1 Mfg' OWNER NAME: OAS f(Lo Gli \abr'i OWNER MAILING ADDRESS: RO (7)(' 1 °15-2 OWNER PROPERTY ADDRESS: -II VO n � !` 12-0 MA-7r c1t') OWNER TELEPHONE NUMBER: m 3�3� 0 O : TAX MAP NO. : Section Block -6 Lot 3-9 CROSS STREET: S "F 74Vc, TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: 0v E1)) 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.) 1 �J Sig t re of Applicant RECEIVED BY: � v� S', ��� ;7 , Tow iC,erk's Offi'e DATE: • MAY 16 1998 C / © _ X3`7 -oo3 of P Np O�N��\- / O,G /: NIoIFP �. \2?• 3i ilk \- os..TT 03O 0 2A 30 �s�a�� kp •60 cd 00� 0% �c o • cF ® s o -, i Z 90`' .<.‘'� x .J o cJPe : % s 9m G (' )?. `6�,� <S9 �i OI 1 T2 Qovi .A°' •"9'®°, ® O ta AO 9 - 0 c:• ..osx.(.•. \oN. , 0 9® s -'55' CP. 9 e 6 ' �' ss\ 9094 . 20,A Z(Da,, \ , �' 94. !y a o \ 73' IOP B > 5Z t e C�� $a. �0 `\` Det V v, 1 -G G, +0��` 'o X23 X61, - r O 9S�0 4,h O �� V. OX [) 'V u_05 , �� \o 206 s r f°pe — O, m� 0. s eo \ 9 AREA = 49,587 SQ.FT. 6, ,-0, "I � .� \261 %\ 0 5 g$ t V fir` g b\o 6Q ` } SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES \\ , \`1\P Approval of Constructed Works H D. Ref. No. 177_f_g_i3 • The sewage a•sposai and water supply facilities at this location have beer' .c TI sin.p „v„ nr'e i by this Depa,tment and are in compi,ance with tr se a •burlt plans. MA-Y-4-3-1988 a - ,, FE DATE SURVEY OF PROPERTY CHIkt OF GENERAL ENe�1ivtartudu SLRVIUES AT "' • MA TTITUC K' TOWN OF SOUTHOLD 1 SUFFOLK COUNTY , N . Y. Prepared in accordance with the mini hum 1000 - 122 - 06 - P/0 29 T standards for title surveys-as established by the L.I.A.L.S. and approved and adopted SCALE 1 " = 50 for such use by The New York State Land AUG 18 1987 Title Association. OCT. 22 , 1987 NOV. 5, 1987(foundalion revised) . ni,ANDS. APRIL 12, 1988 ( FINAL ) N _ /? " :, ' ` f`s; ;7F` M44. ',' I'Vl r ; 4i" � N . • . LIC. NO. 49668 � 2 �161�A v PECO//// ��� `�' ' '.P` 4172 a ENGINEERS , P.0 . c.r, ;�� ( 516 ) -7:, 9 'r`' '`�'f `, c `'_ ' P. O. BOX. 91 ' LOT NUMBERS REFER TO MAP OF MINOR SUBDIVISION{v MAIN ROAD MADE FOR SUNBOW ASSOC'S'' SOUTHOLD , N .Y . 11971 87 — 695