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JUDITH T.TERRY ���_ ?'�: Town Hall, 53095 Main Road
TOWN CLERK ; y 2 P.O.Box 1179
V46)
�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
,�� Fax(516) 765-1823
MARRIAGE OFFICER � `�®���� Fax
(516) 765-1800
RECORDS MANAGEMENT OFFICER d
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. 3506-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WILLIAMS, EDWARD AND ELLEN
Mailing Address 1 P. O. BOX 96
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 16315 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-8700
Tax Map No. section 23.00 block 1 lot 12.001
Cross Street
Issue Date: 8/23/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
II'
-OFFICE OF THE TOWN CLERK c���FD(,r -
`! Town of Southold �o Application3 5 QJ
QG=. No.
Judith T. Terry, Town Clerk �� y
Town Hall, 53095 Main Road a :-� 1 $10.00 - Residential
P. 0. Box 1179 cn ;' $25.00 - Non-Residential
Southold, New York 11971Obi 0*-$
Telephone �.( 4 1P 0• �
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ e
DATE t I t„.20 — nj (�
OWNER NAME: -cba ol- e. )/6_4( um/lin-Hs-
OWNER
I/_Liiq-HSOWNER MAILING ADDRESS: fi-O 601/ 6
A4s7 -4 16 193
OWNER PROPERTY ADDRESS: Ib3/s ,,4711 1 ..Q
S� m4f2lrs27,
OWNER TELEPHONE NUMBER: 447-7- ' '7Dc
TAX MAP NO. : Section -0,23 Block ) Lot DC1 12.(
CROSS STREET:
TYPE OF SYSTEM: 'Septic Tank ctOO y69 New )( Existing
Cesspool3-- �3 4hf New p4 Existing
Residential A 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.)
OW( e (()
Signature of Applicant
RECEIVED
Tow Clerk's Office
DATE: /d3/?d
t _ ' _
{ _ iI SUFFOLK CO HEALTH DEPT APPROVAL
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7;a- f . i c'3rtif`k:ar; ,+d !; ..'st.:.Ad.sci"?;a`:o �� r'.t.-; Vic,-,.. `k a ii I STATEMENT OF INTENT
�"' ,,,,_, 1 THE WATER SUPPLY AND SEWAGE DISPOSAL
' ? '/ w� ;o` _ri c s v;,,, SYSTEMS FOR THIS RESIDENCE WILL-
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4: CONFORM TO THE STANDARDS OF THE
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ou of rd Wwiewsitsr ft aageyit ,, SUFFOLK CO. DEPT. OF HEALTH SERVICES,.
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I' V' '.:11A
o �• SUFFOLK COUNTY DEPT. OF HEAL, H"
Efi.�T' � t ;� j� ,4% t �, ,/ y
SERVICES — FOR APPROVAL •_ •t?F.--q
l ; ti CONSTRUCTION ONLY }
MINN. Ca GSL✓,N.Y. a'' r� '
'• ��ti: �j�_ i-° i �% DATE:
c�,�nreq y�ry' ! iab _ ,,c - -Tr;- - -e vv�l1 H. S. REF. NO.: 21Q-96 -(2
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I \ � 1 !' APPROVED:I =
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+, 1= SUFFOLK CO. TAX MAP DESIGNATION:-
:
r�aQGE.is_ b i DIST.!000 SECT.O2?.; BLOCK!, PCL.1231
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/� OWNERS ADDRESS: -
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r _ y Ilj - "� f I-TEL-516-�,A S1.�7 �-'.;,.I_3-, i 44?�`i_ '',.. V .
c= e . 6c rd?78 -.
,, Om y. �. DEED: L.7221 P.-2C-77 Area' = 54,987 3cr.=•r, 0 , 1ir
rcel 19 J � �' J rt.! TEST HOLE STAMP
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tt,,,afrstio,............tadiso ..-
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i� i • ,, to this survey Is a vlulatl~Ort of
Iw,*y p section 7208 of the New York
V 1 / i U �i50f Fducahon LavR
r Ante rides Feb. (, l9�ro ; bearbg
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q, Yeb. 7, (9 96, r_!, 11396• Copies
re���a s�hrveyor inked sear IX
�, / ` � sandy wmhossed seal shaft not be considered
/
�'iw" AUG.Ir1 ;Jsyt, to be a valid true=N.
.. __- _- -- _ 7t C...arantoes indicated hereon aha/n-i
sr.',to the person for whom the surveil
A S4ndfJ/Gamr .s a-ercred,and on his behalf to the
w _ - - -� - -- .f' rve[cr. cay-svemmentalageccyead
b If -1 Arc. = i \ _ — - — - lend. cn us;ad hereon and
I�G.: - r •-.., . sand i I to the - _ _,cr the lending mstl•
i —_- ----_-------- "_---- -- - 7 - - ( f-• --' tut.c.: _ _ aro nnot transferable
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w 1r , r+%?n ` LICENSED LAND SUR EYORS I ! • y o
rt GREENPORT NEW YORK -� �:� ,
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