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JUDITH T.TERRY ; ® Town Hall,53095 Main Road
TOWN CLERK t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS \ , �, Southold,New York 11971
MARRIAGE OFFICER Fax(516)765-1823
RECORDS MANAGEMENT OFFICER ®d ED *oilTelephone(516)765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1307 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : SUSAN A. SHEPHERD
Address 1 : P. O. BOX 393
City St Zip YAPHANK NY 11980
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #R10-95-0038
Name Of Owner SHEPHERD, SUSAN A.
Mailing Address 1 P. O. BOX 393
City St Zip YAPHANK NY 11980
Property Address 1 EVERGREEN DRIVE
City St Zip CUTCHOGUE NY 11935
Tax Map No. section 102.00 block 1 lot 4.012
Cross Street DEPOT LANE
Building Permit Number Cross Reference:
Issue Date: 4/07/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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a �� 11'' NOWA'
JUDITH T. TERRY .
Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
`` Southold, New York 11971
REGISTRAR OF VITAL STATISTICS y
® � Fax Fax (516) 765-1823
MARRIAGE OFFICER = s,' ® �� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER _ 7®1 1":10°.
FREEDOM OF INFORMATION OFFICER '�"••••,,,, i
OFFICE OF THE TOWN CLERK Fr......__„., ,, /
gu i Gw^TOWN OF SOUTHOLD
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MAR 27 PiT4 Ili
TO: Southold Town Building Department ---_____j
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BLDG.DEPT.
FROM: Linda J. Cooper, Southold Town Clerk's Office TOWN OF SOUTHOLD
DATED: March 24, 1995
Transmitted herewith is a copy of application No. 1355 for a Cesspool/
Septic Tank Construction Permit submitted by:
Susan A. Shepherd _ .
Please review the application and location map and advise if the project
has received Suffolk County Health Department approval and if this office
may issue the permit.
Please complete the form below and return it to me.
Thank you.
aecJ
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE
DISAPPROVE
/
Comments: /IOC // - /O— L
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Signature /9:-..'"
Dated 2/A7/9,S—
OFFICE OF THE TOWN CLERK ,.,,""""' •
Town of Southold /
Judith T. Terry, Town Clerk
14-e.• Application No.(-3
�: .
Town Hall, 53095 Main Road !G ; Construction
P. 0. Box 1179 : =v ": /7'1 Alteration
Southold, New York 11971 ;. .`
Telephone , °,y $10.00 - Residential
(516) 765-1801 1 -)
' $25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Permit No.
Fee $
DATE 312 1 s
APPLICANT NAME: 5Lt +tk0 S `1@pke.2 6
APPLICANT ADDRESS: 0 - ac3 .e a.
LIa? h our( Yt '�,, 1 (-4a-0
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION i1Pet�
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:Il
OWNER OF PROPERTY: 6LtSc J\ 4- ne
OWNER MAILING ADDRESS:
yo h ar, 1� 1� � ( t1SfrO
OWNER PROPERTY ADDRESS: EVEeG2Ff,v 102,
C. LA.T C H•o G ct E
TELEPHONE NUMBER OF-CONTACT PERSON: 36:0 - 0177
TAX MAP NO. : Section JO 2, Block ® l , Lot — Lt- 1 Z
CROSS STREET: r-je-f Lane , C_c) 0 ay.) e.
BUILDING PERMIT NUMBER CROSS REFERENCE:
,I
.4 f i / // I'
Signature of Applica' t
RECEIVED BY:
Town Clerk's Office
DATE:
O2 ti� o T
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Pel34 � /ST FL = /435 SQ,FT
i ;$1i 2N1 FC = 116Z SQ.FT s
z�, .. GAR. = 666 S4 ,FT
i;� N PORCH . /72 SQ.FT
2 c N DECII : 364 .9Q. F7
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Lb T a, THE WATER SUPPLY 0 SE WAGE DISPOSAL
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'PI �� lt, 5YSIES FOR TH/SRES/OENCE WILL CONFORM
T y 2-4 z TO THESTANDARDS OF THE SUFFOLK COUNTY
DEPARTMENT OF HEALTH SERVICES.
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APPL /CANT DEPOT . LANE
SURVEY OF PROPERTY
Situated at Surveyed by
CUT-010611E SMITH UNO ;
TOWN OF SOUTHOLD
SUFFOLK COUNTY —ProfeSSioriai La i 3—cti ve y or
NEW YORK 120 MEDFORD AVE:
SCALE I"$50 PATCHOGUE, N.Y.
Phone 475-3192
Survey Ceht i fled to: for mos. SNOIV/V //EREOM REFER TO "MAIPOFM/ObbS
SUSAN SHEPHERD AT 60-7C-NOGU FI-ED MAI'CW 23,1189—PftE —n-s
STEW/IRT TITLE INSURANCE AGENCY C•C• FILE N°'87/7•
BAY LAND TITLE A6ENCV, INC,
E6TREE YEARS FROM DATE OF APPROVAL
DATES SuFf vEYED : 5 EPTEMBER28, /994- s/EPNERO
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SUFFOLK' COUNTY DEPT. OF HEALTH SERV/CES
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56 4.
'�•� FOR APPROVAL OF CONSTRUCT/ON ONL)
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DATE • ,� : -,:c.-/0 ;KS• REF. NO. �' �� `� (� ®?J
LU0 - / 1
APPROVEDt
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•THIS SURVEY NAS PREPARED /N ACCORDANCE NUN THE EXIST/NG CODE OF PRACTICE FOR LAND URVEYS ADOPTED Bf
N.) LAND SURVEYORS.
• UNAUTHORIZED ALTERATION OR ADDITION TO TN/S SURVEY ISA VIOLATION OF SECTION 7209 OFNEW TOOK STATE ED
O LAND SURVEYOR'S IMRED SEAL OR DMDOSSED SEAL SHALL NOT Be CONSIDERED TO BE A VALIS Meeg cur CERTIFICAT/OII'
FOR WHOM THE SURVEY 1.5 PREPARED AND ON NIS BEHALF TO THE TITLE COMPANY, £OVERNMENTAL AGENCY AND LEND/NEIN.
t4 LENT/MC INSTITUTIONS. CERTIFICATIONS ARE NOT TRANSFERABLE 70 ADD/T/ONAL /NST/TvT/ONS OR SU SEOuENT OWNERS•
u •THE OFFSETS OR DIMENSIONS SHOWN FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A PECIF/C PURPOSE AND
EREC7ION OF FENCES,RETAIN/Ni W4LLS POOLS PATIOS, PLANT/NO AREAS ADD/T/ON To BU/LO/NCS AND ANY OTHER CONST.
• THE EXISTENCE OF R,1H7 Of WAYS AN/ OF EASEMENTS OF RECORD, /P ANY,, NOT SHOWN ARE NOT C A RA WEED.
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