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}` ���� ®® ��� Town Hall, 53095 Main Road
JUDITH T. TERRY
TOWN CLERK L p P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �`' Southold, New York 11971
MARRIAGE OFFICER kVA, O ►�' Fax (516) 765-1823
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„ , Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1837-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOLCHAN, WILLIAM
Mailing Address 1 BOX 1197
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2610 RUTH ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4675
Tax Map No. section 106.00 block 1 lot 3.001
Cross Street SUNSET DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 1/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO(,� '-
Town,,.�of' Southold �� a"" Application Application No. / f�
Judith Td. Terry, Town Clerk Vie' , *47%`
Town 'Hall, 53095 Main Road x ,Y : ) $10.00 - Residential
P. O. Box 1179 53mAf ;' $25.00 - Non-Residential
Southold, New York 11971 Oho
Telephone _ ( 1'►� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
-
Operation Permit No.
Fee $ /0(.00
DATE / A 2192
OWNER NAME: / k4.4.//4,64
OWNER MAILING ADDRESS: e94'ai7—ice IPI9, - ,, ieg7
"47-717-U 6 i / /1/1,
- - - OWNER PROPERTY-ADDRESS: f i`°?
OWNER TELEPHONE NUMBER: (3,76 9,9- 4'67
TAX MAP NO. :' Section 106 Block / Lot
CROSS STREET: 5('//��5 R) /e
TYPE OF SYSTEM: Septic Tank ` New Existing �►�
Cesspool New Existing
Residential 4./ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 41A ei,111
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.)
11111.01116Signature of ' pplicant
RECEIVED BY: w��`'► �
own Clerk's Office
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REVISIONS YOUNG & Y 0 y. `GEk �`r�'Yr .•-I•
NOTE 400 OSTRANDER AVENUE, RIV' ' AD, J�lEW ?ORE,
T =P/PE AUG.28,/975
OCT.9,/975 " =11,OWARD;��'
I• + =MONUMENT OCT./6 /975 ALDEN W.YOUNG ser,
I PROFESSIONAL ENGINEER AND .,r AN Y.S.11C�., `-,
i ' ELEVATIONS ARE REFERENCED TO AN DEC.3,/9T5 LAND SURVEYOR, N.Y.S. LIC. No,12845 F� ° • ''
I ASSUMED DATUM SURVEY FOR: O4. En����``
1 • UNAUTHORIZED ALTERATION OR ADDITION TO WILLIAM MOLCHAN a ERA MOLCHAN
THIS SURVEY ISA VIOLATION OF SECTION
7209 OF THE NEW YORK STATE EDUCATION
LAW
a-
COPIES OF THIS SURVEY MAP NOT BEARING '
THE LAND SURVEYOR'S INKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED A,r GUARANTEED TO:
TO BE A VALID TRUE COPY MATT/TUCK THE TITLE GUARANTEE CO.
GUARANTEES INDICATED HEREON SHALL RUNI\ TOWN OF.
ONLY TO THE PERSON FOR WHOM THE SOUTHOLD
SURVEY IS PREPARED,AND ON HIS BEHALF
1+
TO THE TITLE COMPANY,GOVERNMENTAL
AGENCY AND LENDING INSTITUTION LISTED ,.
1 HEREON,AND TO THE ASSIGNEES OF THE - - SUFFOLK CO., N.Y• `BY/ 'i�/ / _�1 _,
' LENDING INSTITUTION. GUARANTEES ARE /„= /OO/ DATE:MAY7, 1975 X75 T
• _ NOT TRANSFERABLE TO ADDITIONAL SCALE:
I11 - --,- - = -• INSTITUTH)NS OR SUBSEQUENT OWNERS.': - - _ - •.
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