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JUDITH T.TERRY ,��� ®�� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
',� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(516) 765-1823
MARRIAGE OFFICER �� �0-0 Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER .� �► 0 eeP
FREEDOM OF INFORMATION OFFICER ,.00
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3615-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner QUALLS
Mailing Address 1 C/O ELE DEVELOPMENT CORP.
Mailing Address 2 P. O. BOX 1143
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1575 GABRIELLA COURT
Property Address 2
City St Zip MATTITUCK NY 11935-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 108.00 block 4 lot 7.034
Cross Street ELIJAH'S LANE
Issue Date: 4/30/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
)4...t,+-44. 1 0
OFFICE OF THE TOWN CLERK •��FFQ�.�'=
Town of Southold �� (-4 Application No.1011,111
Judith T. Terry, Town Clerk ‘,7;;F,` y
Town Hall, 53095 Main Road t -° . $10.00 - Residential
P. O. Box 1179 v' ' ' l�'*. i ��' $25.00 - Non-Residential
Southold, New York 11971 Oy� °''rsO�,1`
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Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 011ITT
OWNER NAME: t1,L2 t S
OWNER MAILING ADDRESS: 1S-1 S G-� Z�jt'Z V !� I ({ C,¢-`
-Fc c c F< N •`( ( 1 4 52_
OWNER PROPERTY ADDRESS: . t4-t/YVC—
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 1055 Block Lot '7. 3 '4
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool v 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.)
Sig re of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
L J
17� C ct. -! / 7� ✓CI c� 7 3 ( 1
e
.r� oP SURVEY OF •
% �� LOT 10
v' "ELIJAHS LANE ESTATES, SECT. 2
FLED OCT. 8, 1996 FILE NO. 9912
Y ���, e,,• A T MA T Tl TUCK •
\, - s '-..c 4�a9 I 0 TOWN OF SOUTHOL D
sf , 0 - SUFFOLK COUNTY, N Y
e G woo - 108 - 04 - P/071
s Scale: 1" = 40'
Dec. 4, 1996 . 1
,,-5 2e- �'. .
suFropc.COUNTY DIPARTMENT OF HEALTH raw=
- per'FOE AP?VOVAL COP COITlit1FCII01!T 79R.�►..
Sr LI FAINTLY• ' .• ' «. ONLY"`
R = 25.00' .:,DD
L = 39.27 DATE..F.EB 2 0 =9T HS RBP `
' a .�4 i►.. f. 1
v d r ! APhROVED '"' t
0' /VD,,
�j FO MAXIMUM .4
bi • EXPIRES THREE YEARSFROM DATE OF APPROVAL
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• c-,- ,stx T-416e7<- \C?, Uri)
- t.:':f'--=illi F.
I am familiar with /he STANDARDS FOR APPROVAL The locations of wells and cespools
AND CONSTRUCTIOr( OF SUBSURFACE SEWAGE
shown hereon ors from field observations % `7��J•.�° e
n...ea..�.. . M/l�—. a. �.... _ ... P �•..... v i.�c..n�•.... • . . . . . . . . . . , _ • - 4--b `tl •I `7 44A 48.10 -..` -