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' JUDITH T.TERRY I ® #. Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
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REGISTRAR,OF VITAL STATISTICS ‘1'16 Southold,New York 11971
MARRIAGE OFFICER t'101`shy`,=' ®i 1�1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER �►���io�
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. 3704-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BRANCH, DAVID AND ELIZABETH
Mailing Address 1 76 LAUREL ROAD
Mailing Address 2
City St Zip NEW CANAAN CT 06840-0000
Property Address 1 5160 INDIAN NECK LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 203-966-9782
Tax Map No. section 98.00 block 4 lot 23.000
Cross Street ROBINSON LANE
Issue Date: 10/21/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFF_ ICE OF THE TOWN CLERK .cl\TFLU -
Town of Southold k CQG Application No. 3 7�y
Judith T. Terry, Town Clerk -
Town Hall, 53095 Main Road :-(') $10.00 - Residential
P. O. Box 1179 cn �''.' . Mi ;' $25.00 - Non-Residential
Southold, New York 11971 O '*V
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Telephone '�1 `A#, •
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $ / 0. (YD
. DATE B® qqi
OWNER NAME: b4i1J
4— L !6w . 4724 ,erif'/14-61,
OWNER MAILING ADDRESS: 76. /Lie./ 7✓&(
OWNER PROPERTY ADDRESS : 5—/ G O .1— 1/l cLi,'6 ,0 eck. LCLyl
pe_e_o ripe_, A/ ) ( g
OWNER TELEPHONE NUMBER: Z-17 9- (p ' — 5--716---
TAX
V TAX MAP NO. : Section 9 t Block Lot 9:(13
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
- V V Cesspool'''- '-'V- _. -New Existing
Residential ✓ Non-Residential
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.)
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Sign ture of Applicant
RECEIVED BY:
Town I r 's ice
DATE:
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NO.TE,_t J
OUTLINE SURVEY BY ALDEN W. YOUNG P.E. B L.S. ' !I
DATED JUNE 30,1965 -
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/3/Y. 14‘k WI' . i
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Unauthorized alteration or addition to this survey is a violation of is f
section 7209 of the New York State Education Law. v
Copies of this survey map not bearing the land surveyor's inked U
seal or embossed seal shall not be consideree, to be c vcl,d con,' d�
Guarantees or ccriifications indicated hereon shall run only to the p&5471 I
person for whom the survey is prepared,and on his behalf to the l� ` I,,
title company, governmental agency and lending ,institution listed L +'
'� hereon,and to the assignees of the lending institution. Guarantees 0 f
' -et txrr;ficotions are not transferable to additional institutions or / ',
rAiseioeur,t owners,
a • y
F NEW ```` _ -1
At YOB �a�. \K/ s
MAP OF PROPERTY FOR '6y' P, tokT A, ir4 -' `. /7
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DAV/D S. BRANCH _
AT PECONIC ac .�~� n`•
TOWN OF SOUT "' r' kiGp,�d •� 0P
HOLD sr, '0• OP \G
SUFFOLK COUNTY, N. Y. `��t� �' ~'1 �.. °
SCALE• / " _ 100' `>-',,_ '�` �' (9.• (`
SEPT. 6, /9,79 #��� Q
ye.4.4-4. ste...t .
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LAND SURVEYOR 11,
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N.Y.S. LIC.NO.28725 \•
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- RIVERH EA 0,N. Y.
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