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JUDITH T. TERRY L Town Hall, 53095 Main Road
TOWN CLERK _ _ P.O. Box 1179
REGISTRAR OF VITAL STATISTICStrsSouthold, New York 11971
MARRIAGE OFFICER t.
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ye Fax Ak,v e�, Telephone (516) 766) 51801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1648-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GILVARRY, JAMES F.
Mailing Address 1 P. O. BOX 1306
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 BRIGANTINE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5482
Tax Map No. section 79 %.00 block 4 lot 53.000
Cross Street ANCHOR LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/05/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFO(,-
Town of Southold Q -t.. C� Application No., /6
Judith T. Terry, Town Clerk . `
�� $10.00 - Residential
Town' Hall, 53095 Main Road
P. 0. Box 117,9 c
"- . $25.00 - Non-Residential
t ; : hi �
Southold, New York 11971 O ®
Telephone $N°0
(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: - Gt(,v4/-4-/
1
OWNER MAILING ADDRESS: . 'P ® actg. lie(,
2_1.(04,„4o' ...
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OWNER PROPERTY ADDRESS:, mat.i
5c) c17/-Cr D f,3 / ! Y
OWNER TELEPHONE NUMBER: 5/b - 7(47 - „5-487-
TAX
5 8 -TAX MAP NO. : Section 7 47 .. Block Lot
CROSS STREET: ,thy
TYPE OF SYSTEM:- Septic -Tank - New Existing
Cesspool _X New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /V4/ - ei-ectveo -
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of 'distance, approximately, tolbuilding and closest road.)
Qj-j-vaA4
Signature of plicant
RECEIVED BY: '
Town Clerk's Office
' DATE:
4,„
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H.D.Reference No
', SUFFOLK COUNTY DEPARTMENT OF HEALTH
' �� '- .
EASTERN DISTRICT, RIVERHEAD,N.Y.
APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date A`! +- OI:7 j'
,Approval to construct said systems is requested,pertinent data herewith:_
1-Applicant" \NAF_ < +r (.� H_N,/ k71?`' Phone ''J �.,' ' / 6-Sub div- '
- Address - .- - ti), • 1.- r -•'1.1 •- ,-•1 .. 7-Section --
.2-Detailed property location: , - -,-• !. .7). , /: 8-Lot No. .:
Hamlet . - -• -.-,.R ; •Town ::-,,Nk>-„ -Il_,,. 9-Private well?
3-Public water supply name Distance to nearest main
4-Lot Size: Width -.i ft. , Length,.:' ft. (also enter on center plot plan below:)
_ 5-Dwelling: Single Family fJ Two',Family? c'(Cellar? LJ Slab? Lf Crawl Space? V
10-Proposed system: Septic tank L_/Precast 2,__J Cesspools Shallow pools LJOther Lf
11-Septic tank inside dimensions: Volume _Gals.Length_ft. Width ft. Liquid depth ft.
12-Precast sections: LyNumberLJSquare Ft. Cesspools: Block sizeL_incs.D_ins.H ins.
Total blocks below inlet: #1/ -..) #26-,.)#3 -
PLOT PLAN •
Tank ;apacitytGGals.
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The Undersigned CERTIFIES: "Construction of authorized installations will be in
accordance with the Suffolk County Health Departments' current Standards, Bulletins,
and amendments thereto, covering Private Sewage Disposal Systems".
Date (, . `- ,-)j- i`'1lo Signed J , , , J• '---- ',,
%,'Owner or Builder
,
FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the
opinion of the Health Department, that an adequate and satisfactory Sewage Disposal System
, . can be installed on this Plot.
- Date Signed -
•(10/65 Revis.)
S-15