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efeof JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERKA P.O. Box 1179 REGISTRAR OF VITAL STATISTICS 1� Southold, New York 11971 MARRIAGE OFFICER ® ;1 Fax (516) 765-1823 = "_®� , ����! Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1865-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner CZECH, THERESA Mailing Address 1 150 GOLDIN LANE Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 150 GOLDIN LANE Property Address-2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-5753 Tax Map No. section 135.00 block 2 lot 19.000 Cross Street NORTH ROAD Date Of Last Pump Out 0/00/00 > Issue Date: 4/06/92 Judith T. Terry Southold Town Clerk (TOWN SEAL) to OFFICE OF THE TOWN CLERK COFete- Town / of Southold �� s Application No. Fcr- A Judith T. Terry, Town Clerk �� yt ` Town Hall, 53095 Main Road - 8 -� $10.00 - Residential P. O. Box 1179 cry " -. ` , ;' . $25.00 - Non-Residential Southold, New York ,11971 0 ��`� Telephone (516) 765-1801 1 � . TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for ' OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit,No. Fee $ • DATE %' � OWNER NAME: 111NkRESO �'ZE OWNER MAILING ADDRESS: /,5-00 gv L D1lvbi t gnat O 0-7774-0 L,a • GU V 11--, 7> . OWNER. PROPERTY ADDRESS:. j14 in -�� OWNER TELEPHONE NUMBER: 5 5 7n • TAX MAP NO. : Section /3,5' Block Lot /7 CROSS STREET: �' " 'i' •TYPE OF SYSTEM: Septic Tank New Existing Cesspool New '"Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: &4 1.,2,d4) ' l - 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 App ' nt A RECEIVED BY: e LAJ / , 'own Clerk's Office • DATE: SURVEYED FOR:- -7-/-(6--e&—s4 CzE-c '- _ _ LOCATED AT �-cclryOG 0 _ TOWN OF U7-,yp,Gp ._ , SUFFOLK COUNTY N.Y. LOTS __ _ , "CYO �2. ` ,% i3 'o/¢ / --,f---- « -- --. - __ , _ > _ --"`.-= _ MAP OF /(/QT.�/.Q�l GaGO//V P/0/ , __ h SCALE 1" _ �j - - - I. ILI.aoB°O�. Q" , . CO. CLK. N0. //OFILED iC/O V �e'/-9.32 . ----',-- . 5 �: 88. 3 14 SUFFOLK CO. TAX MAP DATA:- - 1i DIST. /000 .SEC. /0.5700 - , n' `J) ` BLK. C:)0:00 LOT C-:),',.000 ' • 1 `0 O- n�loB/G E Nt u )- - - _._ ., ne a 1L. . ., s . -E", IV\ OFFSETS FROM g „,. i , ._ _ ._ . , STRUCTURES - TO RELATJVE BOUNDRY LINES,• % ON SURVEY, ARE -FOR A - • 7.,_ 4 fi-- ° - , : .1PECIFIC USE ONLY, AND - _ ' - _SHOULD NOT BE USED FORb CESs7�o-- CONSTRUCTION //.5 r SOF FENCES _O �2A M!„_(woon/ 1 (� �"�°� �wLG. Ec /,\ -I b‘i ' .k ' 40"•-• 1�. /�\, _ Gua ` - cf.) N . "(\' P4,c1TE .0 z3 '_ TSE-,eEs� C�Fr-�1 !ii 8 - . , _ , , , , lJ _ F,esr _ze/Ty:vlo,P�T- 4 GE. - ,. . . . . ;-" — off- :- .. - -_ -_ - .. -.- --- -- _ - -� --- --- - • -- - -- --- - - S�8'�Z'�'V1l' w� ��X78!J�"• _ - _ 7 70 `� : .1 i : i go/3--------- --- - s - --.;SURVEYED: SE�/r2f� 19B7BY ` ��; ;' _ ____ _ , q - 0 _.--,--- _ : I .- WILLIAM R. SIMMONS JR.. ��� Z1 -•,P/O BOX 377 1 _ f �/` g (o �• JAMESPORT. Lflti, N.Y.=11947 _ • / /— G' FILE N0. // 4�� _" -*-:,PAGE...-„:*._ °= 1 DRAWN' BY t � " __ 'GRID �¢2 4=: 1 �` " -7:-.1-'::::-:,-.!._. - _- - - - _ _ - Via"..+. - ' - _ ...Z`i'•i-tom` - - "_ - - -,;•__:.-2_-_'-_,,,,7- _ _ - - '..-54'1",,-:1''''t1, ---::;74::;:- - -_ _ _ _ -- __ ria..'. _ �'l<"=iv-"_.'.:, _ - __ 'c-�rti G:T' yra g .-m --ff..1---`__ _-:,-2.:.-...: _ _ '-_._ _ - - _ _ _ A-.-e ..z±`.J...w§-t..t3^2/-_.F_-