HomeMy WebLinkAboutSimchick y � j
i°\Ogler
N Town Hall, 53095 Main Road
P.O. Box 1179
����`�` Southold, New York 11971
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JUDITH T.TERRY 6,2 o•' TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 870-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIMCHICK, WESLEY J.
Mailing Address 1 BOX 495
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2475 BEEBE DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5964
Tax Map No. section 103 . 00 block 4 lot 26.000
Cross Street FAWN LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/03/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOntir '- - .�i
Town of Southold �% {¢ 0 -• Application No. , /
Judith T. Terry, Town Clerk 41W. 4.$* 'r y
Town Hall, 53095 Main Road a � z- .,r�j' 7 Residential
P. O. Box 1179 -{§-
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cn rte: "�{�� � Non-Residential
Southold, New York 11971 O ® w�� /, ,
Telephone Q( ).a� �
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. glo
Fee $ /,e)
. DATE 9:4.. ?br
• OWNER NAME: ),,/6-51., EY I 5 //1Ch'/C1e
OWNER MAILING ADDRESS: 8,x 4 f
Carc6a6 t� , /V}`�// ,5-
OWNER PROPERTY ADDRESS: 24, 75— g1.7,, ,,4--_
Gu i eRa , ,, ,iv v. // c/1 ,—
OWNER TELEPHONE NUMBER: 7 5 z/--.6.7‘ i*.
moo
TAX MAP NO. : Section / 0 Block 0 9' Lot D 2. 6 •
CROSS STREET: ZF j Ovf AI rR Wil/ L4ivc /I-/VP' ngse Y / O4-L7
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I,.,-"--" New Existing
Residential •k Non-Residential
DATE OF PREVIOUS PUMP-OUT: (./ C 7 /�/ / q ,r 7
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.)
/ /1A
rY
Sig(ri;tur 'of Applicant
RECEIVED BY:
Town Clerk's Office
RECEIVED
DATE: n-
vua 03 i9.64
Town Clerk Southold
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11. Zone or use district in which premises are situated1.,
.....
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12. Does proposed construction violate any zoning law, ordinance or regulation:� o '
13. :Will lot be regraded 'MO Will excess filly be removed from premises: ( ) Yes ' • ,( ) No ' ;,
14. Name of Owner of premises . 4!.s.51:E.. ..........,;5/tl•01/.Kg,gddress eif.T..C•fteg." Af phon . N 7.1q.: . ..,•.t
Name of Architect ..L. k.v/S Erl 5T,j ov - " • e' No.
T7 P Address !El N. 4/ /, yphone� No. 7.2 7-2i/3-
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, Name of Contractor •. MaTfM Y C 2e.Wi4/ y • - ddressi?Yelef. 5Q• (� ,KKPhon .2
,...,:,;;‘,,,,PLOT DIAGRAM „ :v ., ,: .7 •-:t�e: .{: ..', ',i- :iis .
':-Ti$Locate clearly and distinctly all buildings, whether existindor proposed, and indicate all set-back dimensions-from
)roperty lines. Give street and block number or description according to deed, and show street names a_nd indicate. -
thether interior or corner lot. _ - --__ __
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:, LOT 2 — ' .VI21.1+ 1.11' �1L1:11`i'. C....!-1,:).72.‘..C....!-1,:).72.‘....:•:::t•1`: . L. •, J
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ATE OF YORK 1
JUNTY OF�'.C.k.t.F'0.. .1<-. ......1S.S _ --�
being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
love named. •
is the O
, �/�//2 -
. ,
(Contractor, agent, corporate officer, etc.)
said owner or owners, and is duly authorized to perform or have performed the said work and to make and file
s application; that all statements contained iri' this application are true to the best of his knowledge and belief; and
.3r the work will be performed in the manner set forth in the application filed therewith.
am to bore me this
/6 of , / . 19..73 . - /
tory Public,� P: ,..�.'! '.... . Count ' i . .f
ANNA W_ ' OBS Signature of applicant) ,
• Notary Public in State of New York '
No.52-7057150 — ;
k@siding in Suffolk County
Odnii-ltlssidn Expires March 30, 19 7 _