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fOlir JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK ® '7 r-ri P.O. Box 1179 REGISTRAR OF VITAL STATISTICS ;S� ' Southold, New York 11971 MARRIAGE OFFICER Fax .�� Fax (516) 765-1823 -69419/ �� � Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1741-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner GEODESIC HOMES INC. Mailing Address 1 BOX 13248 Mailing Address 2 25 CORPORATE DRIVE City St Zip HAUPPAUGE NY 11788-0000 Property Address 1 715 WAMPUM WAY Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-862-8140 Tax Map No. section 87.00 block 2 lot 28.000 Cross Street TEEPEE TRAIL Date Of Last Pump Out 0/00/00 Issue Date: 8/28/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) 1 Y J x OFFICE OF THE TOWN CLERK c��FFIlC,�,-. /7 // Town of Southold V® _ CQG Application No. /7 / Town Judith T. Terry, Town Clerk ` b .",' 4,:-.:` , . Town Hall, 53095 Main Road -� $10.00 - Residential P. O. Box 1179 to „j , $; $25.00 - Non-Residential Southold, New York 11971 %O , _®�,,1 Telephone = (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. j'74// Fee $_ it) DAT E-`_� ,7/ OWNER NAME: :'";Z)(Pe-fce 441-j/L-4S- _19.-1(-- OWNER MAILING ADDRESS: ilgOC /321 La&'rem° OWNER *PROPERTY ADDRESs7/C, ).Gl= :_ h!' ,„ir l ei L - L-t9 OWNER TELEPHONE NUMBER:_____, TAX MAP NO. : Section O?1 0 O Block 02 , 06 Lot 02r, 60 d CROSS STREET: "Ji/L. - 1' -J ! 7 .rigor, /r -- Jr ".A-' TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential IV Non-Residential DATE OF PREVIOUS PUMP-OUT: st �&- Fr 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.) _ / . -.dd.). #//igfat .;�- o Applicant RECEIVED BY: c.�.--i e- • Town lerk's Office - . MEMO DATE: AUG 2 81991 town QOM l . SUFFOLK CO. HEALTH DEPT. APPROVALti f �?`y� .i b'rr+ers{ floor \ H. S. NO. `� \ (hew/ �. \(GZf` B.O' abtuv `r+ } © � rrrean sea level =� `„ r� \ 4, NI g rade. -, �' \ , (` =caG�-:- .fir `. / r' \� S shallow /oral, s`2 �t$2. l''\\ fiF� / a\ _ ` sar-rd et gr'v1. min.12� e0'" �i`• `� �` 1 �V groUrsd wo ter STATEMENT OF INTENT ‘q /06'°4-6) THE WATER SUPPLY AND SEWAGE DISPOSAL Q / k >> �.tyil. .-• A i{ �'' SYSTEMS FOR THIS RESIDENCE WILL ~ 7q'l�- �r��.%A %` f CONFORM TO THE STANDARDS OF THE t,$, we,/i t --v'.' 441/•-;` ra ®rte �i R0P ---� }� W : � `,� i i SUFFOLK CO DEPT. OF HEALTH SERVICES. Ws �"o' SCJ, t,/,a- Y',L "G')A.' (s) �� "t , 1 ei �� APPLICANT Ff. .moi \ �/ . ; !'� r e,..--I: �' {'z � ad�, \�+`.!_� rar�~1fr �" r'` ;.� i o f V fC : /� j// SUFFOLK COUNTY DEPT, OF HEALTH•• �jI !l r1 %� SERVICES — FOR APPROVAL OF ,� co �r� .%� ' ,I 0.. C. / CONSTRUCTION ONLY n, ` ki �J�(.J T^ n�.&) / DATE: '9. °Q, , �„I /, c:\-.% ols �r H. S. REF. NO.. ,: 'ro d A� i ` APPROVED: ,'. �� • ! �. / /�� •"�'� i __5'_-_ . SUFFOLK CO. TAX MAP DESIGNATION: L - .�` j .a4,� I I 11I, It • DIST. SECT BLOCK PCL. • V �0 `—"� ! - OWNERS ADDRESS: C? .�1 Yea „ �. ,�clCtr� s' ifi 7 7'7 t rye 7 f "i C?� ��.--,-.\' 7✓r, f L`d.-� / d,c12 l`,>-' ,- / / -J 2-1 ✓2 •"_'"" l.f,�w''-L.3L:1. !Y''�"r-‘,(,, '-i�•- . ` . , 1 �...0+ 5 4 .. -.. ,ti , \ T ' . A/ j/ r 'el— (574) m`6` _ --8/4 0 ' I `'e /m 1 e_.,'.1 , 1 /vote C !L�4s1�t:�'i :;r�r( '✓rrfG'e v k''4'`c.- �0 1'y7 't�-, •: c�� (.'=4 \\'‘), T /r.t ✓'-'-'•-;.1 \, i 1`f. r0.�y,, ' ,?5 e:.', I- 1'ii ;n r i;` F71 A= Lff� ,f--�.'r �ye: ,,c / ' 3l f��,'t' DEED: L. N/A P. �. _�, '�C' �/ 1 -_ '-' ` / .. _� Iej�� _, / TEST HOLE STAMP ;`� i y f • N.a �& Q i 71 ha f'? /we a ri c...4, e v.=r1 j . IPTWO tIZFD A:Iiw'nii rN UA A51111100, '! _ �'`� s ,...-'� \•T; l LO 7 ' SWrtVEY Is A VIOLATION OF.td,.., \ .- ,,,e, J IXTION 7209 OF TWE Ni:V.' YORK STATE;"� . " ,y } S rTe�3f[7�'111�J off` s'x.f." $� ATIOw LAw.�4, .`iu� crsr. -• r,'ry \..ti`,t.0 ' Y • JL.ine 2J, l C 8-` .' •. �jt"oposC.1 i e, . 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(�� f / I 6-3? ✓ l �yv"d e . 0•I I.Y11,'' ir'._"K. r , >f.`,1.�.r'i,...-•4' r 4.' r"'' -- /r x��� c� ( T is) ,— t+., /ll f ` H.� dl �/ r • 1(LL 111: �,, -�4 tom." ° S'. " / ��'?� �" RODETCK VAS N TUYL, P.C. , 1 LICENSED LAND S'�rU EYORS , GREENPORT NEW YORK ' • TELEDYNE POST N32477