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M * t Town Hall, 53095 Main Road
A 1 P.O. Box 1179
= ® - ` .cZr k.7 '� Southold, New York 11971
JUDITH T.TERRY -,, 1,0TELEPHONE
TOWN CLERK �__,,,,I” (516) 765-1801
REGISTRAR OI•VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 756-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner RADICH, JOSEPH
Mailing Address 1 960 GREENFIELD LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 OAKLAWN AVENUE EXTENSION
Property Address 2 '
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4394
Tax Map No. section 70.00 block 10 lot 12. 000
Cross Street TUCKERS LANE
Date Of Last Pump Out 0/00/80
Issue Date: 7/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
s - a -_`! r` • iii i
OFFICE-OF THE TOWN CLERK
Town of Southold �� �. CQG'_ Application No.
't :-1
Judith T. Terry, Town Clerk � �6a"`, y
Town Hall, 53095 Main Road P. ri ) Residential
P. O. Box 1179 cra xw `' Non-Residential
Southold, New York 11971 O 441°14;-"
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Telephone 0( �� '°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 32
Fee $ •
DATE 7`"
OWNER NAME: 1-6S p 1r('lfD (Cl-f
OWNER MAILING ADDRESS: q C c' q R P� /V 5 P 1 L
Ov hOCA
OWNER PROPERTY ADDRESS: /1- (( L O W~ ( 4 tit" d%)(`
S o u E I‘ 0 L )\_y_
P
OWNER TELEPHONE NUMBER: 7 6 V. 473
TAX MAP NO. : Section 70 Block /0 Lot /-
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing -r
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: —7— t V/l..4-9
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.)
//a-LA
Sign ure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
- SUFFOLK COUNTY DEPARTMENT OF HEALTH
se
EASTERN DISTRICT H.D.Ref. No. SV-- /(-/
County Center, Riverhead, New York
PA 7-4700
APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
Inspection for •approval is requested, pertinent installation data herewith.
1-Name of Owner TOSj',4' ,P,qp/C/f 3-Subdiv.
Address gK/AIYN/9//.F £XT s,Ur/fol.L mg PhoneSD c-337/ 4-Section No.
2-Name of Builder .S,9M4" /fsAwork- - Phone 5-Lot Number
Address 6-Bldg.Permit No.32S7*Z
V 7-Sewage System installed byiflohie 7ARp,P Phone 323-26t '
Address eRejyAg pD .ST.J,Qip/.FiYT /Y,/,
8-(a)Deed location of property E�S 0,94-1,40'4/4,4k-Yr) 29,e-foP5/i�/.F/t'.E-eiFiP.a.
j (b)Hamlet or Village SOG!?!/odD (c)Town soirhohp
0 9-Septic tank-Gal L ft.W ft.Liquid Depth ft.
10-Cesspools-(a)No.pools 2 (b)Blocks below inlet-1) 2) 3)
W (c)Bo ck sioze-L in.W in.H in. (d)Precast pool )( (e)1_2 ,3
D0/w_ (f)H ft. ,uin; Diam ft. in. (g)Finished grade to cover 2 ft.
ac fill MSterial$ ',/b to 1 R4t/EL
it-Water Supply: Public System ; Private Well X
If Private, the following questions are to be answered:
12-Private Water Supply System installed by TOJ,Ep/ ,p9/J/C// PhoneS,p.-4=332/
Address OAR:14 "/ APE; .t=X7..; SPL/>fi�OLD)A/f�
N 13(a)-Total Depth- of Well 33y ' (b)Depth to Static Water Level /..r/
1 14-Diameter of well pipe 2 in.
15-Name of Laboratory 16-Method of Disinfection -
17-Date -ready for inspection D,FC,2;779a
The undersigned CERTIFIES: Above systems have been constructed and are
in compliance with the Suffolk County Health Department's current Standards, Bulletins
and Amendments thereto.
18-Dat a,lEC,2 /9vl' Signedg/aCtoeLf....4
Owner - Builder
19-Insert sketch of location of Wate l`& Sewerage Facilities with accurate dimensions.
"i "• — _ _ SO`- - - - —
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N - — — as/
QUI, AwA' AIDE E2(1 STREET
F H ARTMENT USE ONLY
Inspected by �) �� ��/ Date
p /4 / 3-4,7
Based upon the informat on stated above, satisfactory functioning of the
above systems can be expected with proper maintena ewnd re
MAR 8 1968 '� „f (P
" . (),e
Date Approved \
S-5e