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JUDITH T.TERRYGy1 Town Hall, 53095 Main Road
TOWN CLERK ` 1=3
P.O. Box 1179
+�t i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS `® ��
y ��,� Fax(516) 765-1823
MARRIAGE OFFICER �=� �®�i§� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER 1
FREEDOM OF INFORMATION OFFICER - ,40.°�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3517-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner GAFFGA, JESSE J.
Mailing Address 1 3350 GRAND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3350 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5771
Tax Map No. section 107.00 block 2 lot 4.002
Cross Street MILL ROAD
Issue Date: 9/30/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN. CLERKS�� '
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Town of Southold � 44 G'_\ Application No. a5
Judith T. Terry, Town Clerk 6.1-
.
Town Hall, 53095 Main Road ;<� $1 .00 - Residential
P. O. Box 1179 cn ;'
$25.00 - Non-Residential
Southold, New York 11971 O *.$
Telephone • q1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD- WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7-30-5,6:
OWNER NAME: � S� 61A�F`��
OWNER MAILING ADDRESS: 3350 GrW
' to-e to(sz.
s
OWNER PROPERTY ADDRESS: 3 -O -
OWNER TELEPHONE NUMBER: O`li?- 5)7 1.
d
TAX' MAP NO. : - Section (� - Block . Lot
CROSS STREET: ty,,\\ 0-3
TYPE OF SYSTEM: Septic ,Tank , , New Existing •
Cesspool New Existing
Residential fir.. 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.)
)1941ielt-e of Applicant
RECEIVED BY:
own Clerk's Office
DATE: 744/FG
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1 NOTE.
I 1 ■=MONUMENT FOUND 41.=STAKE FOUND
2 LOT NUMBERS SHOWN HEREON REFER TO SUBDIVISION MAP-
1 "GREGORY SIMONELLI"FILED IN THE OFFICE OF THE CLERK
OF SUFFOLK COUNTY ON SEPT 20,1995 AS MAP NO 9743
3 ELEVATIONS SHOWN HEREON ARE FROM TOPOGRAPHICAL
MAPS PREPARED BY US REFERENCED TO MEAN SEA LEVEL
DATUM AND ARE SUBJECT TO FIELD VERIFICATION
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES CERTIFICATION SURVEY FOR:
'I AM FAMILIAR WITH THE,STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE
SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES AND WILL ABIDE BY THE CONDITIONS JESSE J. GAFFGA do
SET FORTH THEREIN AND ON THE PERMIT TO CONSTRUCT'
APPLICANT'S SIGNATURE JENNIFER A. KRUSE
APPLICANT At: MATTITUCK Town of: SOUTHOLD
STREET ADDRESS Suffolk County, New York
CITY STATE ZIP CODE
TELEPHONE NUMBER SUff Co Tax Map: , 1000 I 107 I 2 I 4 2
District Section Block Lot
CERTIFIED TO'
Young & Young, Land Surveyors JESSE J GAFFGA
JENNIFER A. KRUSE
400 Ostrander Avenue, Riverhead, New York 11901 FIRST AMERICAPI TITLE INSURANCE COMPANY OF NEW YORK
516-727-2303
JUNE 25, 1996
/� NOV 27, 1995
/t
Alden W. Young, P.E A• L.S. (1908-1994) 1 DATE OCT 5, 1995
fie
!toward W. Young, Land SurveyorL J SCALE •lc= 60'
Thomas C Wolpert, Professional Engineer JOB NO 95-0868
Kennelh F Abruzzo, Land Surveyor SHEET NO '1 OF 1
71 :;;;;;:;
Surveyor (GA950868 DWG)Ff
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