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S Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY .01
FAX FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 975-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner BURK, RONALD G.
Mailing Address 1 169 EAST MADISON STREET
Mailing Address 2
City St Zip EAST ISLIP NY 11730-0000
Property Address 1 145 HICKORY ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-277-3137
Tax Map No. section 54.00 block 9 lot 6.000
Cross Street CHESTNUT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
„.,,
--6- FICE OF THE TOWN CLERK as1Fac,�
Town of Southold o�r `Q ” Application No. / -
Judith T. Terry, Town Clerk . �Aff
Town Hall, 53095 Main Road "
Residential
P. O. Box 1179 cn � ; " i ‘ Non-Residential
Southold, New York 11971 01 +r _`-
Telephone
_o.( 43. o'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - for - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /:9-/ai /17
OWNER NAME: O/4/79--c-o 6 6ag-ic
OWNER MAILING ADDRESS: F6- 9 c. //4 #12/50.' ST
- 1- c. c /2/, A7-y_ / / 7) ,,
OWNER PROPERTY ADDRESS: P-I5 /--Ac /colt/
.9v7-Hoc. /Y }7 //7 Lo
OWNER TELEPHONE NUMBER: ( 5/6) ? 77 - 3 /3 7
TAX MAP NO. : Section S Block 9 Lot .0
CROSS STREET: C,y -5T1vv 7-- X
TYPE OF SYSTEM: Septic Tank New V Existing
Cesspool New V Existing
Residential t"7- Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
•
Signature of A pplicant
RECEIVED BY:
Town Clerk's Office
DATE: 1-14-i-7 L
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SURVEY FOR
RONALD BURK a VERONICA BURK SEPT.I2,1988
MAY 2, 1988
APR.8, 1987
AT SOUTHOLD DATE: FEB. 6, 1981
TOWN OF SOUTHOLD SCALE: I 30'
SUFFOLK COUNTY, NEW YORK NO. 81-25
*UNAUTHORIZED ALTERATION QR ADDITION TO THIS GUARANTEED Te-q" pF b
SURVEY IS A VIOLATION OF SECTION 7209 OF THE USLIFE TIT,.'tiA - , + E GO OF NEW YORK
NEW YORK STATE EDUCATION LAW
*COPIES OF THIS SURVEY NOT BEARING THE LAND �1® C)
SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL
NOT BE CONSIDERED TO BEA VALID TRUE COPY O� �0
*GUARANTEES INDICATED HEREON SHALL RUN ONLY TO . .1. -C7-
THE PERSON FOR WHOM THE SURVEY IS PREPARED
HEALTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUCT �Y +.-, e
AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERN- / �, a</
* NEAREST WATER lAIN_MI.± *SOURCE OF WATER• PRIVATE_PUBLIC_ MENTAL AGENCY AND LENDING INSTITUTION LISTED I _;jf If
#SUFF CO. TAX MAP DIST 1000 SECTION 054 BLOCK 6 LOT 6 HEREON,AND TO THE ASSIGNEES OF THE LENDING y
*THERE ARE NO DWELLINGS WITHIN 100 FEET OF THIS PROPERTY INSTITUTION GUARANTEES ARE NOT TRANSFERABLE
OTHER THAN THOSE SHOWN HEREON. TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT ` ' a
OWNERS f E! �� `
# THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FOR THIS RESIDENCE
*DISTANCES SHOWN HEREON FROM PROPERTY LINES tk , i }'
OF HEA •
WILL LTH SERVICES.FORM TO STANDARDS OF THE SUFFOLK COUNTY DEPARTMENT TO EXISTING STRUCTURES ARE FOR A SPECIFIC D f r EyO� TP
APPLICANT, PURPOSE AND ARE NOT TO BE USED TO ESTABLISH WD SURd 2RC��
PROPERTY LINES OR FOR THE ERECTION OF FENCES
ADDRESS �/ A' �/ NG TEL 1 O�I V� 1 O U 1 V t7 RIIVOSTRANDER VERHEAD, NEW YORK E
NOTE _ ■ =MONUMENT
ALDEN W.YOUNG,PROFESSIONAL ENGINEER
AND LAND SURVEYOR N Y_S LICENSE NO.12845
HOWARD W.YOUNG, LAND SURVEYOR '
*THE LOCATION OF WELL(W),SEPTIC TANK(ST)11 CESSPOOLS(CP)SHOWN HEREON NYS.LICENSE NO.45893
ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS
TDY POST E0494