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JUDITH T.TERRY • Town Hall, 53095 Main Road
TOWN CLERK t cop P.O.Box 1179
n � Southold New York 11971
REGISTRAR OF VITAL STATISTICS N. ® cj °�-
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MARRIAGE OFFICER � ���'� ®•i� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = 1°010 Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER — 0088
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3679-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FALSTEIN, BRUCE M
Mailing Address 1 MACKENZIE, KAREN C.
Mailing Address 2 P. O. BOX 481
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4505 ALVAHS LANE
Property Address 2
City St Zip CUTCHOCUE NY 11935-0000
Owner Telephone No. 516-734-4077
Tax Map No. section 101 .00 block 2 lot 23.000
Cross Street ROUTE 48
Issue Date: 9/04/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
0FF10E OF THE TOWN CLERK /c��FF�(�•�'� '
Town of Southold �� CQ =.\ Application No.3(o "/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< $10.00 - Residential
P. O. Box 1179 tri * ;) $25.00 - Non-Residential
Southold, New York 11971f`'•
,a1
�Telephone * 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
•
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE p • /3
� ,J
OWNER NAME: ZRucc , ra/.stet r, Rpm Macq/fe/e
OWNER MAILING ADDRESS: PD , gax4cff
so krt-tvid, N y f l'7 /
OWNER PROPERTY ADDRESS: 4.5o5 t Avg-
OWNER TELEPHONE NUMBER:( /6) ?34- 4-07 7
TAX MAP NO. : Section /01 Block Lot4'2,3
CROSS STREET: Igr. (y. 0,114.) IvipU'r., 44 (ftit )
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:
wn Clerk's Office
DATE: � /7?
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O Guarantees indicated here on than rail; Copies of 9his survey
only to the person for whom the survey the land Surveyors Qeenbossed seal shal9
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41 is prepared, and on his behalf to the not be considered to be a valid true
o title company, Govermental Agency, copy. \O
0 luting institution, if listed hereon, and o
- the cssignees of the lending institution. h
Gveroetees ore not transferable to Unauthorized alteration or addition to this
survey is a violation of Section 7209 of
additional institutions cr s.bsaquZnt owners. tr.
the New York State Education Low.
'SCM Fd N 340 58' 40" W /88. 43 '
Next to
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N IF DROSCOSKI, CASSIDY, VAL/ENT
TMa/000-/01-02-23 MAP OF SURVEYED 22 MAY 1992 ,
DESCRIBED PROPERTY
SCALE / ` = 30`
SITUATE
CUTCHOGUE, TOWN OF SOUTHOLD
SUFFOLK COUNTY, N.Y. '
GUARANTEED TO SURVEYED FOR BRUCE M. FAL S TE/N SURVEYED BY
BRUCE M FALSTE/N KAREN . MOcKENZ/ STANLEY J /SAKSEN, ✓R
KAREN 6 MacKENZI£ / PO BOX 294
FIRST AMER/CAN TITLE /NS CO. J NEW SUFFOLK,NY, /1956
.11/ / / ' (5/6)734-5835
TOWN OF SOUTHOLD
/LICENSED AND SURVEYOR
NYS L/C NO 49273
92R 480