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JUDITH T. TERRY < Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS o : Southold, New York 11971
Fax 516 765-1823
MARRIAGE OFFICER �-
e49 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. 1926-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WHITE, WILLIAM
Mailing Address 1 P. O. BOX 250
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 515 GIN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2724
Tax Map No. section 88.00 block 4 lot 5.000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE,OAF THE TOWN CLERK cvFFOUrI'=
Town of Southold Y CQ Application No. /
Judith T. Terry, Town Clerk Y ' i4
��., .c I $10.00 - Residential
Town Hall, 53095 Main Road iERr .
P. O. Box 1179 v' tri
_ ��"''°_� $25.00 - Non-Residential
Southold, New York 11971 O,,e �0 �`
Telephone `�jto
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Q
APPLICATION
for
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ ow
DATE 6 - IS- 9
OWNER NAME:Dr. W I l l Iaxn 1A 1 f€-
OWNER MAILING ADDRESS: � '� �(, c
OWNER PROPERTY ADDRESS: 51 6' ry - -LCUn e,
5oc 'io/ c1
OWNER TELEPHONE NUMBER: 7 (,5 - �
TAX MAP NO. : Section 0 Block LIT Lot
CROSS STREET: aMakin
J P
T,YPE ;OF,SYSTEM: Septic Tank '✓'Y' - --New Existing
Cesspool ✓ ' New Existing
Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT: kj f Sty-re- ,he- re 118x? C'i )oi c.� )
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.)
44:17 //#
Signature of Applicant
RECEIVED. BY:, bQ -
• Tow Clerk's Office " � "�" � _��-��� ° -- - _.....
DATE: _ _- '
•
JUN 17 'MPS
Town Clerk' SAM
DATUM APPROXIMATE +�
LOT AREA 15625 SQ FT the xis RCe of right of ways and or easements
7 ,< MAP DISTRICTC TI O N 1000 e 1N a h�v oT record, if ani.not shown are not guaranteed. N
U
BLOCK 4 MP' i'---
LO T 5
O
0
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in
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LOT NUMBER 21
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0 (64 )
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( by others ) ri F C 0 4'N r`
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( 8.0 ) ®(83 ) (9 2) 6t-=
n N 52 °05' 50 "W 2500 1d\-C 10'N
sand wire Ton 09'E
e fence x
gravel LOT NUMBER 19
5 NOTE• SEPTIC lANK,CEsSPG0L AND WELL
DWELL ING - WELL LOCATIONS BY OTHERS
wat er FINAL SURVEY APRIL 15,17H2 OFFSE IS 10 FOUNDATION
SUFFOLK COUNTY DEPT OF THE WATER SUPPLY & SEWAGE NAME
HEALTH SERVICES FOR DISPOSAL FOR THIS RESIDENCE `
APPROVAL OF CONST. ONLY WILL CONFORM TO THE STAND- ADDRESS •
•
DATE ARDS OF THE SUFFOLK COUNTY
H S. REF. NO. DEPT. OF HEALTH SERVICES.
r
APPROVED BY TELEPHONE
_._.,
DIE OFFSETS (OR UII+ALNSIUNS) GUARANTEES LNUILATEO NEr,EOh JOB N O. 8 0 - 34 3 FILE N O. B AY HAVEN
SHOWN HEREON F R 0 M T H E SHALL RUN ONLY TO THE PERSON
STRUCTURES TO THE PROPERTY FOR WHOM THE SURVEY IS PRE (i
'INES ARE FOR A SPECIFIC FUR. PAPED, AND ON HIS BEHALF TO SURVEYED FOR JAMES ME 0 /V1
'OSE AND USE AND THEREFORE THE TITLE COMPANY GOVERNMEN
'RE NOT INTENDED TO GUIDE TILE TM AGENCY AND I,NDING INSTI LO T NO 20
RECTION OF FENCES. '.E1eMING FUTION I1"IFn HEREON, AND 10
"AI LS, POOL S, PATIOS. PI ANTING VIE 1551^'FES OF TILE I ENDING
i:EAS, ADDITION TO BUILDINGS hiss rwric,I Cr'^R`NFFES ARE MAP OF BAY HAVEN AT SOU T HOLD
It ANY OTHER CONSTRUCTION - NO T'7•nMr,^,R'F 10 ADDITIONAI
INSTITUTIONS OR SI'TISFQTIENI
IAUIHORIZSD ALTERAT ION OR OWNERS SITUATED AT SOU T HOLD
NIT ION TO THIS SURVEY IS A
'101HE Of SECTIONATE7209 OF COPIES RIN OF TLEIS SURVEY MW VE NUS TOWN OF SOU THOLD - SUFFOLK COUNTY N Y
IHE NEW YORK STATE EDUCATION BEARING THE lANO SURVEYOR'S
AW INKED SEAT OR EMBOSSED SEAL
SHALL NOT BE CONSIDERED TO BE SCALE 1" = 30' DATE 9 - 2 - 19 80
A VALID TRUE COPY
GUARANTEED ONLY TO FILED MAP NO. 2910 DATE 1 - 22 - 1959
BOOK NO. L L PAGE
HAROLD F. TRANCHON JR. P.C.
- LAND SURVEYOR
SUCESSOR •TO WILLIAM G. MEIER
--/J—;./‘--
is
NORTH COUNTRY ROAD - WADING RIVER
- f/'- / NEW YORK 11792
L N.Y. LIC. N2048992
H RO D F. TRANCHON JR. PENN. LIC. N.O. 21115E (516) 929-4695 ALT. 473-3626