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JUDITH T. TERRY 1Town Hall, 53095 Main Road
• TOWN CLERK p rZ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; � Southold, New York 11971
MARRIAGE OFFICER yQ �' � Fax (516) 765-1823
+ �1D®��� 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. 3075-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANDRUSKI, HELEN
Mailing Address 1 1775 LITTLE NECK ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1775 LITTLE NECK ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5244
Tax Map No. section 103.00 block 5 lot 1 .000
Cross Street FAWN DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 7/27/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •ir�FFair
Town of Southold ��:a CQG Application No. 3 7._C
sy
Judith T. Terry, Town Clerk � ? P 4 �
Town Hall, 53095 Main Road i $10.00 - Residential
P. O. Box 1179cry � '` ►�� $25.00 - Non-Residential
Southold, New York 11971 O� ® " `0*��`
Telephone _9®1 [ l�•
�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7—
OWNER NAME: *'4 6„44,0
OWNER MAILING ADDRESS: //,,,%/—
/193:5-
-- OWNER PROPERTY ADDRESS : - - .. _
OWNER TELEPHONE NUMBER: 5/6;_ 73.9.— 61:2 9
TAX MAP NO. : Section /®3 Block S. Lot
CROSS STREET: f46il17
TYPE OF SYSTEM: Septic Tank V New Existing
Cesspool New Existing C/
Residential r% Non-Residential
DATE,OF PREVIOUS PUMP-OUT: (p//6//p�
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.)
1//024/9--r
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
9I '7.1-.-...-,_h
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1 ..z, N . NOTES
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1• DATUM = ASSUMED 23.0 ELEVATION
<D,.? ?2 c'2 OF NORTI-4\VEST CO2NER OF PREMISES
N.89' 50' 5O \V. 150.0 1 <' 2• NO EXISTING lVELLS AND/OR
' CESSVVOOLS ON PROPERTIES
DUNNU(3Ea, 100 FEET FROM PREMISES
33'--7
SCALE . 40 ' -- 11T
O = IRON PIPE
MAP OFPROPERTY U = MONUMENT
S U 2.V E 7 E D FOR UNAUTHORIZED ALTERATION O• ADOIT1
r TO THIS SURVEY IS A VIOLATI•N Of _
{ T1— �, 7.) 1 - 1A,.
/ 1T SECTION 7209 CF THE NEW Y•'E1 1— F \�•1 QNI i f ` �J S1 CATION LAW. STATE _ -
/� COPIES OF THIS SURVEY MAP N•T BEARING -
SITUATE AT THE LAND SU'VEYOR'S INKED S •L OR C
EMBOSSED SEAL SHALL NOT BE •ONSIDERED 0 SURVEYED • JAN, ' , I cL1 -
1 r /^ ''l r. 1 I TO BEA VALID r wE COPY. P. C.
■ r 1 �: TuGUARANTEES IND,G;7cU HCREO SHALL RUN "�^ Lt �=I:Y1 Ur F Y i_
TOWN, 7: -.;J U 1 ,i T� L,r),f•1 Y ONLY TO TEL P�:�;S.D.,,,FOR W;,Ora TY.E SURVEY 1_,.,_ -
IS PREPARED, A:0 Oh 1:.0 s...1-:ALF TJ THc
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TITLE COMPANr, ,;.,�r_;-,,,...",,A..
LENDING InST,TUTI:.,N l:S..0 l:_,,:0_,_S,�
TO THF ASSGP,CES OF T,:I. L-.c":G! LIC.EN5CD L-ANDi :V•'YOOti.S
TUTIQN. GUAITANIELS A..,.u, T....-.;r,,...x.a; G R E E N P 0 IL T , NEW YO:e.V.
TO ADDITIONAL INS.i....• _ ,_, ,Fr
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