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JUDITH T.TERRY ; ®ms `% Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
1`k. ; ; Southold,New York 11971
REGISTRAR OF VITAL STATISTICS : ® Fax(516) 765-1823
MARRIAGE OFFICER `I=4f® ® ��� Fax
(516) 765-1800
RECORDS MANAGEMENT OFFICER .0;0
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3738-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MOYER, DALE AND STACEY
Mailing Address 1 650 BAY AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 650 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9583
Tax Map No. section 143.00 block 3 lot 12.000
Cross Street ROUTE 25
Issue Date: 12/02/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK $0 c0FU
-.Town of Southold &,% , eQG Application No. 7367
J.,vcI th T. Terry, Town Clerk -r. „>: .e...41. -
''' '*' $10.00 Residential
Town Hall, 53095 Main Road
p. O. Box 1179 u' LL• tri �`'
$25.00 - Non-Residential
Southold, New York 11971 , ,. �`��
,a ,oma-,.
Telephone : .( * '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE ///20/97
OWNER NAME: Dale f Sacey / 1 er
OWNER MAILING ADDRESS: V Ave
y
iivG // 45,2J
OWNER PROPERTY ADDRESS: Fc5 above
•
02,71OWNER TELEPHONE NUMBER: 6/6 9515
6/6
TAX MAP NO. : Section li,t Block 0 Lot 0;U
CROSS STREET: ae ,
TYPE OF SYSTEM: Septic Tank 1 New Existing
Cesspool New Existing
Residential V 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.)
I
761
Signa ire of Applic. t
RECEIVED BY:
Town Clerk's Office '
DATE:
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REVISIONS YOUNG & YOUNG
400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK
ALDEN W. YOUNG HOWARD W. YOUNG
-PROFESSIONAL ENGINEER AND LAND SURVEYOR
LAND SURVEYOR. N.Y.S. LIC. NO, 12845 N Y.9. LIC. NO. 45893
SURVEY FOR:
UNAUTHORIZED ALTERATION OR ADDITION TO
THIS SURVEY Is A VIOLATION OF SECTION • DALE D. MOYER & STACEY L. WAGNER MOYER
7209 OF THE NEW YORK STATE EDUCATION
LAW �-
�°"``:tr OF NFnY
COPIES OF THIS SURVEY MAP NOT BEARING Y
THE LAND SURVEYOR'S INKED SEAL OR I' S 0 4"i O'P
EMBOSSED SEAL SHALL NOT BE CONSIDERED •A y 'f"
TO BE A VALID TRUE COPY AT GUARANTEED O. Z y �>3i^e•- G
MATTITUCI< USLIFE TITLE INS RAID E CO.O��F,'N 0(.ta i 0
GUARANTEES INDICATED HEREON SHALL RUN . ROBERT COSTAN jj' tl��3,1'"`•�
ONLY TO THE PERSON FOR WHOM THE TOWN OF m.0,...�..,n. n 1-t4 `� 1