HomeMy WebLinkAboutMellas G ;
JUDITH T.TERRY ` t _�® .01�. Town Hall, 53095 Main Road
TOWN CLERK y = P.O. Box 1179
w t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ;® �� � Fax(516) 765-1823
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MARRIAGE OFFICER Q oil.
RECORDS MANAGEMENT OFFICER ;_ e41 `°01°° Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER r ,0°.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3544-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MELLAS, PAUL E.
Mailing Address 1 43 SUNSET LANE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 43 SUNSET LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-1477-2283
Tax Map No. section 33.00 block 4 lot 53.000
Cross Street SUTTON PLACE/SOUND DRIVE
Issue Date: 11/15/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ` PFFD //1
Town of Southold �oC® ? Application N �7
Judith T. Terry, Town Clerk $10.00 - Residential
�
Town Hall, 53095 Main Road t C.
P. O. Box 1179 cry i) $25.00 - Non-Residential
Southold, New York 11971 O "' ��`
Telephone4,01 r ,,.0
(516) 765-1801
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE //�/"9- J7
qiir°
OWNER NAME: a �/
1
OWNER MAILING ADDRESS: '
eVe V, /V
OWNER PROPERTY ADDRESS : / (
OWNER TELEPHONE NUMBER: , 5-74 (17 7
TAX MAP NO. : Section-33 -11-5-3 Block Lot
CROSS STREET: �/
TYPE OF SYSTEM: Septic Tank - ) - New Existing
Cesspool 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.)
-2.,t ?;
r` of Applicant
Signature pp
RECEIVED BY: - -
Town Clerk's Office
DATE:
1� ,IFJ . i l r,C) -
''4 SUFFOLK COUNTY DEPARTMENT•OF HEALTH
•4 - EASTERN DISTRICT H.D.Ref. No. 3b -
County Center, Riverhead, New York
y PA 7-4700
C,k
1r; APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
Inspection for approval is requested-, pertinent installation data herewith.
N1-Name of Owner Pepil E . MQ i`o 3 3-Subdiv.
Address 7/2 3'±--s c4 4 ) ( bivalif-Phone Y 77-2 ?�4-Section No. --
W 2-Name of Builder -- 0, ),„•R — Phone 5-Lot Number-
r 7
qr Address 6-Bldg.Permit No. 3° .
I 7-Sewage Syst install by - • . . C; =1,_ _� Phone 7/7 2 Y5"c
A Address � d a t& A4,4ifh>e 1 g.c? .0 1.--) owl i'- . /l q s-7
UN 8-(a)Deed location of properfy 1W. Sita uhSIP - £a4 A
(b)Hamlet or Village (`2, `RAkp0wt (c)Town S'a11 c L-(
9-Septic tank-Gal L ft.W / ft.Liquid Depth ft.
10-Cesspools-(a)No.pools (b)Blocks below inlet-i) G,f 2) J6t3)
(c)Block size-L in.W -- in.H ? in. (d)Precast pool (e)1_2_3
(f)H ft. in; Diam ft. in. (g)Finished grade to cover /itft.
• (h)Backfill Material Std .
L11 11-Water Supply: Public System EYVs:,., o .-t ; Private Well
If Private, the following questions are to be answered:
12-Private Water Supply System installed by Phone
'`r•-) Address
G1 13(a)-Total Depth of Well (b)Depth to Static Water Level
1, 14-Diameter of well pipe in.
15-Name of Laboratory 16-Method of Disinfection
17-Date ready for inspection
C
�`' 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. I -% i
18-Date h41 2 g Signed i L. i �
. !,
if cr Owner - :uilder
19-Insert sketch of location of Water .& Sewerage Facilities with accurate dimensions.
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LT, -7.' —c It n s e L L. Ai -r _ -
STREET
FOR HEALTH DEPARTMENT USED LY '
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Inspected by - b ;`f' Date 6,'-'4.-
,`^' . / 6
Based upon the information stated above, satisfactory fungt'o:ii s of :lie
above systems can be expected with proper mai pnc an r,9_ /�:/
di (l.�e (J
Date 1UP1 2 8 1968 Approved District-I-. Engineer
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