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OFFICE OF THE TOWN CLERK c0FO(A'1,
Town of Southold
Judith T. Terry, Town Clerk :e 4 , L:
Town Hall, 53095 Main Road z a ,
P. O. Box 1179 .cry41.4.. `
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Southold, New York 11971
Telephone el ,,;
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 52 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool XX
PERMIT ISSUED TO:
NAME: Edward R. and Sharon Schmidt
ADDRESS: 200 Southern Blvd,
Nesconset, New York 11767
DESCRIPTION OF PROPOSED CONSTRUCTION or ALTERATION
New One Family Dwelling
LOCATION OF PROPOSED CONSTRUCTION or ALTERATION:
OWNER OF PROPERTY: Edward R. and Sharon Schmidt
OWNER MAILING ADDRESS: 200 Southern Blvd.
Nesconset. New York 11767
OWNER PROPERTY ADDRESS: 180 Grathwohl Road
New Suffolk. New York 11956
TAX MAP NO. : Section 117 Block 6 Lot 10.3
CROSS STREET: New Suffolk Avenue
BUILDING PERMIT NUMBER CROSS REFERENCE: Pending
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Judith T. Terr
Southold Town Clerk
DATE : October 3, 1986
r(TOWN. SEAL) '\
OFFICE OF THE TOWN CLERK
Town of Southold ' 2
Judith, T. Terry, Town Clerk Application No.
Town Hall, 53095 Main Road Construction
P. O. Box 1179
Southold, New York 11971 Alteration
Telephone Residential
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVED
sEp 2 9 1986 APPLICATION
Town C erk Southold for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit •
Fee •$ /0 c.
DATE -e-'Ytii-e ) c,7 9 ) ! ?
APPLICANT NAME: bte)ML /Q f 5/44 ,20/0 ,Se/0/ 0 L 7-
,7,1
.',`1" APPLICANT ADDRESS: c Oe 4O12-t 2A_n) 66
1l ejr_, • 2•V1/ 7/ 7
r SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
laj dJe)L.P,ee
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
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OWNER OF PROPERTY: �i', �' j / f eJ lit/ -�� ' L'
OWNER MAILING ADDRESS: Sa4yy(2_
OWNER PROPERTY ADDRES5 v� iL.0_6_,0, ,
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TELEPHONE NUMBER OF CONTACT PERSON: GJ -0 93 `/
TAX MAP NO. : Section // 7 Block Lot �� d
CROSS STREET: //Qa hf
BUILDING PERMIT NUMBER CROSS REFERENCE:
_
Signature of Applicant
RECEIVED BY: r
Town g Jerk's ffice
DATE: .�,�e.CJ c fS/
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SUFFOLK CO. HEALTH DEPT. APPROVAL
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CONFORM TO THE STANDARDS . OF THE
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' . . LICENSED LAND SURVEYORS
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GREENPORT NEW YORK
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TELEDYNE POST N41239 .. ' •
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