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JUDITH T.TERRY � - -- �� ; Town Hall,53095 Main Road
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TOWN CLERK =. >.-, P.O.Box 1179
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REGISTRAR OF VITAL STARISTICS \\ � V Southold,New York 11971
MARRIAGE OFFICER �# Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER :�®f ib„d Telephone(516)765-1800
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. 3312-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BURKHARDT, WILLIAM
Mailing Address 1 P. O. BOX 1047
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 170 WABASSO STREET
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5790
Tax Map No. section 78.00 block 3 lot 41 .00A
Cross Street MAKOMIS ROAD
Issue Date: 3/09/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
sOFFjCE OF THE TOWN CLERK '
Town of Southold „C�VFFO(KC' _ 39/
OHO �' �G Application No.
Judith T. Terry, Town -Clerk' y- �. y ,
Town Hall, N.�, $10.00 - Residential L/
53095 Main Road Viµ• r �� -
P. O. Box 1179 cn ;. $25.00 - Non-Residential
Southold, New York 11971 p ® 1F *$
Telephone J�( ‘0 -'.4*
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 3/3/9'S
'OWNER NAME: Pr, Winn wt 5i v1 h q rd1T
•
OWNER MAILING ADDRESS: BOX ( O 7
4,7 , .i f i l l'7l
OWNER PROPERTY ADDRESS: 170 W,`j/, 5$c) S7.
OWNER TELEPHONE NUMBER: 1G 57 €)
TAX MAP NO. : Section 07 0 Block 3 Lot PA y/,
CROSS STREET: Nokom15 RI -
• TYPE OF SYSTEM: Septic Tank / New V Existing
Cesspool t/ New / Existing
Residential (/ 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 Applicant
RECEIVED BY: � �s
Town Cle k's Office
DATE: 3 3' ��
- SUFFOLK CO. HEALTH DEPT. APPROVAL I f
ff - H. S. NO. 2.O-9 0O9! '‘✓
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l•1A R o� PtzoRE-2T _
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SC1iZVEYED Fol
49.5, 1:
�/ll _L ;4E - Bvfl j /42-07-
n/f W1c c-1A1� ^�� ,ci7.y^ STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE DISPOSAL
LAUG(--�•(A(G WAye72
I SYSTEMS FOR THIS RESIDENCE WILL
' TOWN OF SOU T(-101_0, NI.Y. i CONFORM TO THE STANDARDS OF THE
1,1.86.'31'30"a
I SUFFOLK
LK CO DEPT
OF HEALTH SERVICES.
(23.20 (5)
SUFFOLK COUNTY DEPARTMENT OFHEALTH SERVICES I APPLICANT
SINGLE FAMILY��siCC.6tWAy J I
WELL .N
Ij�, d ( a a ®f SUFFOLK COUNTY DEPT OF HEALTH
L1! �-3q` —
`�� \`9� �_� °° � FES 1 6 .1995 �` t /G' -a;,�-��C)�/ ": SER VICES CONSTRUCTION ONO
LY APPROVAL FOR
K.�a. �.6�.�
} I r' Z The selfrrng eeporial end watersf� DATE
; moi, 0 , at t I0r I WM"bSfAl insp,•: end/or Q(O-94- 0091
H. S. REF. NO
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-- — 47.r . . ' ( . Nit r r tett f; t`to zags e't.tow. . APPROVED
,0 _ so Q ;- - . i I SUFFOLK CO TAX MAP DESIGNATION:
i- — _ is O •
8t phen �A.� P.E.,Chief ; I DIST SECT. BLOCK PCL.
- { Nz- WAy urzy VF • GAR_ '`� 9 1 C\ O . , Office of Water and Wastewater 9�aiement 00 /o (.1
WITH 6t4T , l Q �Q IQ 07� 4
' =�, . Trtilf R/3 # OWNERS ADDRESS•-
NcQT,c to _ Area= 14, 207 sq. fes.
0 1 ! 5532 EkffViW Zooid
V ., - . - ` - �C'ihe j Soc1f(ad(dV_Y, ( ((c-7(
5.8k:!',322"lp - -�'
'W_ 115.69 f
q ' I . 7-e1. 7G5 579
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- • I I • DEED: L. P.
1i 1 ' TEST HOLE STAMP
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6Ut21. HA T
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Atrrencf'cJ Feb_ (3, (995
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----___..-___ -. I Survvc fwd O _30, (994 p`; 1 ;j
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__ RODER/ICK VANp;jUYL, P.C. -1.•-:--'..\1;G.2.4-,.,.-S 25c••/ 1/
_ _ LICENSED LAND SURVEYORS `6 ...n_..-._- ,
GR£ENPORT_ NEW-YORK
-8 if DYNE POST N81329