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Suskevich
JUDITH T. TERRY "e.014' Town Hall, 53095 Main Road . P.O. Box 1179 TOWN CLERK . 7Z REGISTRAR OF VITAL STATISTICS ® T Southold, New York 11971 MARRIAGE OFFICER �� Fax (516) 765-1823 . �®i �r Telephone (516) 765-1801 7 1sit '�� •rrr/rI,,'I' OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1670-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner SUSKEVICH, WALTER Mailing Address 1 1015 ROBINSON LANE Mailing Address 2 City St Zip PECONIC NY 11958-0000 Property Address 1 1015 ROBINSON LANE Property Address 2 City St Zip PECONIC NY 11958-0000 Owner Telephone No. 516-734-6567 Tax Map No. section 98.00 block 5 lot 5.000 Cross Street INDIAN NECK LANE Date Of Last Pump Out 0/00/00 Issue Date: 4/19/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) ^-t OFFICE OF THE TOWN CLERK cOFO(,1(�'- Town of Southold w CpG Application No. Judith T. Terry, Town Clerk ae; y 4_.J; Town Hall, 53095 Main Road La $10.00 - Residential P. O. Box 1179 En 04 K�•. � $25.00 - Non-Residential Southold, New York 11971 O ® _ $ Telephone 149°1415(''- � '°• (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ • DATE /9P21L - /9 ' OWNER NAME: /1/29Lraie. 6US/<EvIC. H • OWNER MAILING ADDRESS: /C/S 461A/SO4/ 1•IAI,E /0 CoA1' 41 /. //q Wig' _ OWNER PROPERTY ADDRESS: 0i9/4Z , S A-60 er= OWNER TELEPHONE NUMBER: /181/1 - Cp TAX MAP NO. : Section 9 Block 5 Lot 6-- CROSS 'CROSS STREET: ZN©t,3nl AlE.c.K �oca 7) TYPE OF SYSTEM: Septic Tank ✓ New V Existing Cesspool ✓ New � Existing Residential ✓ Non-Residential DATE OF PREVIOUS PUMP-OUT: U71.Ai • - / f J 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.) /1i tzeLL 2 4 .41_;. L Signature of Applicant RECEIVED BY: L - n Jerk's 0 fice DATE: ��/ ' SUFF.CO. HEALTH DEPT.APPROVAL J H.S.NO7"50-r57 X OWN :. ,. -, 1,. /7 ,-1/4 -� SUFFOLK COUNTY P.YIiLTH DEFARTMFNI ' I/` J A `- ' i -- 1, '}_, -77 ; / f JUL 6 1978 ' Z 5�-O? 87 a' 2D. DATE A. D. REF. # 7,SD X.$7 The sewage digin l 1 r +• y T� 67---C.Or='AL c='�A, fC,r'1f 4�' 1( >I osr._. and tat.P_ cupply (Tel 212-343-8085 facilities for this .1. e tic: hove teem by thin -d:'y-_trtuent and found () AREA: 20,855 �?.f. - to be SatiSfact ../.-. a V , DEED: Nfr:4 allot of GeuFrL 1 Engineering . o , i-4-11 :cervi "_G j Z'• ,n Ca . r-_Ul ' cvrbe-i •' LOT . Z( (residence) ` '% , •Q0.; bIc �ILo,drive e ir O _ _ _N.T3"43'30"E. . - 211.57 , !i a A- ;+i of *y o• —tom Ts , —t rcwo�l::ine.� .. _ - - - --.-- - - (\J N d e 1.vC Ya r, L_ , 4 N tel. O k). es- • - ',Dols 8. r- L ,U - 47 . - ------—...c, ----v • 'D Q 613 O i9 ...ea .. >> - '.I '� '8 v 6 ? 5.7�3`43'30' W, — 207.71 _ rL '9 (( 3. C:::0 •- i/ /A, SCALE:040'=1" LOT 10 .-cs ttfonumerre- (vac:cr rrt.) O G iron pipe I • D - ill l • 1 , A S;ar*,ed e1Fv.7-orc:+�(ora4,rt+: �'� 20.0 al- NVt7 corner. / •..... ' �` dO THIS SURVEYISA VIOLATION OF � f'1 SECTION 7209 OF THE NEW YORK 51^01 l-, Vy CO' EDUCATION LAW. b -' �J COPIES OF THIS SURVEY MAP NO7 BEARI _ THE LAND SURVEYOR': IN:L_D SEAL OR C.' A I EMBOSSED SEAL SHAT: NOT EL CONSIDER ^►1 TO BE A VALID TEL' _�F1. �' 1 ` i ! ! GUARANTEES I>,C:_� . ;NA!L . I ONLY TO it _ •'•,,,' i A. tS RETACEL.f.:. • . _ . . 1 E COM'&t.'.- - .._.. - , , ? TM . LE9F NG II,V44,_. .. . . . , r, TITLE + CERTIF. • Tl4TaTJ,� saLa j TO hr..m.a4G+,,.• I.- d• '7+K'wCIS T Gvararr feed-fn W1 STAMP MAP OF ! Q. ?7 4r*-1er:corrl -r I'f/e /r5u,sa'rrce Gb 1.20,rcr SEAL Alr�EGCQN/G COi:'.Y DAK5- and i #re 5ocrf{cold 5auings Bank/� (Su--01k G ) a. File MClrb No.8431{ ars Surveyed June 8 ,!975 AT RODERICK VAN TUYL P. C. Pcorvlc . I 7744/cv c.).= 0L1Ti-/o-0,IL!`! / LIC..I-AND SUP.VEYORS.GRE.:-NPORT. N.Y SufFolk. C . T7,, ;Mar Desiarrai•iarr:0151. /000, 5ecd.09S,&/ock- 5 l—of S TEST HOLE SUFF. CO. DEPT. OF HEALTH SERVICES STATEMENT OF INTENT O' FOR APPROVAL OF CONSTRUCTION ONLY (nog- THE WATER SUPPLY AND SEWAGE p eil ) DATE: DISPOSAL SYSTEMS FOR THIS REST- S 1 DENCE WILL CONFORM TO THE H.S. REF. NO.: - STANDARDS OF SUFFOLK CO. DEPT. OF HEALTH. SERVICES. APPROVED: .. • (S) - -� APPLICANT 17' 1 \