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JUDITH T. TERRY .� Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK tai
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER 44 Fax (516) 765-1823
deV®ei! Telephone (516) 765-1801
2S ED JO
OFFICE
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1856-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner VANMATER, ROBERT & ANNE-MARIE
Mailing Address 1 P. O. BOX 1231
Mailing Address 2
City St Zip MONTAUK NY 11954-0000
Property Address . 400 MOCKINGBIRD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-668-4867
Tax Map No. section 55.00 block 6 lot 15.054
Cross Street TUTHILL ROAD EXT.
Date Of Last Pump Out 0/00/00
Issue Date: 3/17/92 Judith T. Terry
Southold-Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c�VFFO(,(- = -
Town of Southold CQ.?" Application No. Ag
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ! ~ 7 $10.00 - Residential
P. O. Box 1179 trig' $25.00 - Non-Residential
Southold, New York 11971 4 •
0-1/
Telephone ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE -7-›— \„( •
.0
- OWNER NAME: (-4-0 9,e1L-C A uto L-X-14 KJ 6,— VIA A.rif ,A
OWNER MAILING ADDRESS: PO lax La31j
//9 ECY _
OWNER PROPERTY- ADDRESS: u4 OO- ()"" t(t..( L A
S o tz-N-4 o`- 1`V
OWNER TELEPHONE NUMBER: 5;--7e, -C 66 g- V , 7E)-›
TAX MAP NO. : Section S S Block (� - Lot
CROSS STREET: 7vr/-// �-�-- f•L),91J C'Jx i
TYPE OF SYSTEM: - Septic-Tank "==" - - " - New Existing
Cesspool X New y Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: . 1),2,„..,),
- LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
RECEIVE') _ - - -
DATE: -
RAI 16199?
- Town Clerk Southold
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SURVEY FOR
ROBERT A. VAN MATER 81 ANNE-MARIE VAN MATER
LOT NO.48, 11HIGHPOINT MEADOWS ,SECTION THREE"
JAN 8, 1992
AT SOUTHOLD DATE NOV. 19, 1990
TOWN OF SOUTHOLD SCALE 1“= 40'
SUFFOLK COUNTY, NEW YORK NO 90 -0913
*UNAUTHORIZED ALTERATION OR ADDITION TO THIS CERTIFIED TO
SURVEY B A VIOLATION OF SECTION 7209 OF THE ROBE'. ' ,:"A."'TER
NEW YORK STATE EDUCATION LAW AN'•' .i1',1•R VRItig. ',.T ER
M COPIES OF THIS SURVEY NOT BEARWG THE LAND y„ �_ Pt:-JtONAL BANK
SURVEYOR S INKE0 SEAL OR EMBOSSED SEAL SHALL ICO` W113"L ID •'L �3.0 "A+" E
NOT BE CONSIDERED TO BE A VALID TRUE COPY
*GUARANTEES INDICATED HEREON SHALL RUN ONLY TO ►ISy�Lp'. 0 EAST SE ffiI:, I',e. ORP
THE PERSON FOR WHOM THE SURVEY IS PREPARED T1, -S A -IN T1:1, -- 1 SURANCE
HEALTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUCT AND HIS BEHALF TO THE TITLE COMPANY, GovERN- COM Y e ARK
MI _ *SOURCE OF WATER PRIVATE PUBLIC _ MENTAL AGENCY AND LENDING INSTITUTION LISTED 4 1.'" R
* NEAREST WATER WAIN— 55 BLOCK G LOT 15.54 HEREON, AND TO THE ASSIGNEES OF THE LENDING -++ ,
II BUFF CO TAX MAP VAST 1000-SEC SETHION INSTITUTION GUARANTEES ARE NOT TRANSFERABLE
II THERE ARE NO DMIELLINBf WITHIN 100 FEET OF THIS PROPERTY TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT
OTHER THAN THOSE SHOWN HEREON OWNERS } • �
* THE WATER SUPPLY AM SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENT *DISTANCES SHOWN HEREON FROM PROPERTY LINES
WILL CONFORM TO THE STANDARDS OF THE SUFFOLK COUNTY DEPARTMENT TO DiEx STANCES
STRUCTURES ARE FOR A SPECIFIC
OF HEALTH SERVICES PURPOSE AND ARE NOT TO BE USED TO ESTABLISH ..reo r., 0 Sl)s••:.`,
APPLICANT PROPERTY LINES OR FOR THE ERECTION OF FENCES -1., I
ADDRESS 400 OSTRANDER AVENUE
TEL $ ; YOUNG a YOUNG RIVERHEAD, NEW YORK
NOTE ■ =MONUMENT O - STAKE 1 ALflEN W YOUNG,PROFESSIONAL ENGINEER
SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF .•4 r`€,., AND LAND SURVEYOR N Y_S LICENSE NO 12845
SUFFOLK COUNTY ON MARCH 19,1990 AS FILE NO. 8912. HOWARD W YOUNG, LAND SURVEYOR
*THE LOCATION DF WELL(W),SEPTIC TANK(ST)11 CES3PODLS(CP)SHOWN HEREON t' NYS LICENSE NO 45893 7 a
•,-,• u c1Gtb oe/sERMATIONS AND OR DATA OBTAINED FROM OTHERS