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-JUDITH T. TERRY . ` Town Hall, 53095 Main Road
TOWN CLERK ® rri P.O. Box 1179
REGISTRAR OF VITAL STATISTICS - �� Southold, New York 11971
rFax (516) 765-1823
MARRIAGE OFFICER ®� ®�" •
,y® jg. �� 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. 3188-R- Residential X Non-Residential
Fee $ 10.00 New X' Existing
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Name Of Owner VANBOURGONDIEN, MARK
Mailing Address 1 1950 BOISSEAU AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 GRANGE ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5300
Tax Map No. section- .00 block ---4 lot 12.000
Cross Street BAYVIEW AVENUE
Issue Date: 3/23/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ' c��FFO(,r
Town of Southold Q eaG; Application No.3/?0
Judith T. Terry, Town"Clerk' ��`s.1 �' `
~ - $10.00 - Residential
Town Hall, 53095 Main Road ..,s-�
.a- ,y x i
p. O. Box 1179 u-3 �r:.-% ; -;.L $25.00 - Non-Residential
Southold, New York 11971 p `® `.- „=-
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Telephone _ Q( " ‘K '••
(516) 765-1801
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 412-1q(1-
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OWNER NAME: !rW• 1).P71\-- (2-1,3etledo
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OWNER MAILING ADDRESS: Ig o `?�( Celle, ae .
tda
OWNER PROPERTY ADDRESS: 6A41- Q et r --0,. -kek
OWNER TELEPHONE NUMBER: ')3<i- — Bg2-o
TAX MAP NO. : Sec. • Block Lot ic9--.
CROSS STREET: �A " v'l ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New x Existing
Residential > Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
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Sign, ure of A..•licant
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RECEIVED BY: /1-1
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Town Clerk's Office
DATE: 3 /Z -_
N/O/F
CHURCH OF THE OPEN DOORel)i , i4
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` ° SURVEY OF
P/OLOT9
SOUTH HARBOR HOMES"
FILED JULY 14,1964 FILE NO. 4096
AT SOUTHOLD
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
1000 - 75 - 04 - 12
Scale: 1" = 30' •
Prepared in accordance with the minimum Dec. 9, 1993
standards for title surveys as established
by the L.I.A.L.S. and approved and adopted
for such use by The New York State Land
Title Association.
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<- NEW pOp
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES co ,,,2, t. METI-Fp
FOR APPROVAL OF CONSTRUCTION ONLY - - f:r`
92 SO 97 The water supply and sewage disposal i J/ -`�,,, Y.S. LIC. NO. 496/8
DATE HS. REF. NO. systems for this residence will conform IL \i %
to the standards of The Suffolk County PE?ONI '' e.IR VE. O'S, P.C.
' Department of Health Services. (.16 765 9 X: ; r
P. 0:��<< ;, . . 1 7
APPROVED � D :.
SOUTH' ' N.Y. 11971
93 - 305