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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3498-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner YOUNG, RANDY
Mailing Address 1 875 AKERLY POND LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 875 AKERLY POND LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3404 f3� 3
Tax Map No. section 69.00 block 5 lot ,i
--- ///5/97
Cross Street ROUTE 25
Issue Date: 8/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
of
OFFICE OF THE TOWN CLERK
4 � IIS
,Town of Southold ® CQG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road • -< $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 O ;' 0�.1`,
TelephoneOl Y►`a �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ /0 ,00
DATE g411)._.0
OWNER NAME: ,,eAA/0y 1/4gni
OWNER MAILING ADDRESS: 8`75 Ave-RL ?®iii Lb4,05
SOcA,ate '1• Writ
i
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: L5.10 7 —3g07
TAX MAP NO. : Section ®( CI Block Lot f®/® /3
CROSS- STREET: F„ t
TYPE OF SYSTEM: Septic Tank • ` _ New Existing
Cesspool New Existing
Residential 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.)
{ 1'
Signa+'fofr,li nt
RECEIVED BY:
V Town.:Clerk's Office
DATE: • -
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SUFFOLK CO. HEALTH DEPT. APPROVAL ' r
H. S. NO. I i- 50-5.( 1
• n
IN
• ' • STATEMENT OF INTENT
THE .WATER SUPPLY AND SEWAGE DISPOSAL '
' , ,SYSTEMS .FC R{••• THIS RESIDENCE WILL
MAP OP* f Y • . . CONFORM TO n THE STANDAR DS OF THE
SuQv - o FOQ SUFFOLK -CO. DEPT. OF HEALTH SERVICES.
J. MMQY UNG H
APPLICANT '
AT SUFFOLK COUNTY DEPT. OF HEALTH
SOUTf-40L0 SERVICES — FOR APPROVAL OF
-- t:%'''-' ,,�- v,.•s,� ••,P ,: .CONSTRUCTION ONLY' '
LJ FLOLaC C.4JfJl!�('7 y, ' ,L', ',' , DATE: • .
' H. S. REF, NO, 11- SO-51 - ,
APPROVED: • - ,
`
SUFFOLK CO. TAX MAP DESIGNATION: ,.,;:' 's:,
DIST. SECT. BLU;CK PCL. ; ,,N
` 1000 0/9 ' 5 ' No'18'
• OWNERS ADDRESS: ` "1
St S Cltxrl� ted. . ' ` i. '
SorJfhotd N.` 11971 ••
Scot le . SOta 1"
V (MI: 765-2413) ' d
Area = 42i 810 sei.P1; r s: .r
i root pipe DEED: L. 4531 P. 1549 slots f.) , ,' '
'.TkST HOC , STAMP, . '`;,k
, 4NAUTHORlZPD ALTERATION OR ACDII1011 ,
TO THIS SURVEY IS A VIOLATION OF
' SECTION 7209 OF THE IIEW YORK STATE ',. ,
��(1 EDUCATION LAW.-Pop •"
Yo•
• .-_..t . LAND
OF THIS SU,".VEY APAP HOT MARINO
THE ND SU,VEYOP.'S IIT:4 SEAL OR
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_ '' }•. 'I ,• ,r, ;t, '',F70 BE A VALID
j; � TRUE CCPY.
, ° � GUARANTEES INDICATID HT1'O`7 SHALL ON
, , ' solid aM ONLY TO THE PES SOl I FOP.WI'OMA MIMVP -
)S PEEI'ACED.ANC Oil HIS CI-HALF TO VIA
lea Vel, . YULE cclll^AI:Y,G:iyrR);TALTtiSAL A I7:TCT/.ND
"`'""" _ '•"'"' 5 LENL'NG 1t1STUUTIOII t.'S!TD IIJION,AM) ,
70 THE ASS:CD!P
Y 1ZS OF 1HE LEyIG I S15. J
TUIION.GUARANTEES ARE t401 1LA.lAT)tfABIf ', /;L
' I TO ADDITIONAZ INSTITUTIONS Ok yUDSTOUEN, '
t =01/NERS, ,
G& circir ived -to 1 { .,
•Cofiima-rw ,li4r Lapid tills 1Hsur tucb C43,• io
F- , SEAL
argrue1 Houeinq Admin.,0e1: :of l-kxisjtt5 4,
Urban C�sVJ rniifti;otttd'io L artdl Mot-corp., "� id
C15 surveyed Marl 2'9, 1982. -
RODERICK VAN TU . Pt: ' ,
LICENSED LAND SURVE ORS I
GREENPORT NEW YORK