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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4481-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner LONG ISLAND ONE REAL ESTATE
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Mailing Address 1 PO BOX 13
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Mailing Address 2
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City St Zip EAST MARION NY 11939-0000
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Property Address 1 12910 MAIN RD
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Property Address 2
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city St zip EAST MARION NY 11939-0000
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Owner Telephone No. 631-477-0472
Tax Map No. section 40.00 block 2 lot 17.000
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Cross Street WEST WPPD
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Issue Date: 2/27/15 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
V
•' S�EFO(,�-�O
ELIZABETH A. NEVILLE Gy� Town Hall, 53095 Main Road
TOWN CLERK va = P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS • Fax (6Ne York 45
RECORMARRIAGE
S MANAGEMENT OFFICER y��l 1i �aO� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
ial 10 $25 Application No.or Non-Residential
Resldent @ $ @
Permit No. d?
Owner Name Lv-'`1
Owner Mailing Address
Owner Property Address �'11 A 0—V
Owner Telephone No. ��� G 7y
6G�
Tax Map No: rtion ' Block � Lot
Cross Street �st'' J u 0
Please check each that applies: New Construction
Alteration to Existing System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approx ce in feet from system to building
and closest road. New construction may sub op of surve with SCHD approval.)
�.
Zz
tute of Applicant ate
Received by:
Survey for:
f SUFFOLK COUNTY DEPA?T"ENT OF HEALTH SERVICES g� BRYAN VILLANTI
keTl U7
PERMIT FoR AP: .9 VtiX CF w0??S+RU--T!0 1 1=0R A ��„? �� e<�°�° G6
SINCLot 89 "Eastern Shores Section 2"
70
i..:� rA;riis„'; ':y'i0i: v0� �{�j'� • ff lOv� > >
\ L,
i N. At
DATE r �-':�. rivF'. ��0. i o.... c-0 t 3
/ ° Greenport
PPROVED GClec } v7 Town of
FOR PlIA,:IRiiihl OF ` ` c \.off $a 00 OQ �� �z� ..°o Southold
S EXPIRES THREE YEARS FROM EcOR00N1S \\�n9 W p N n � = Suffolk County, New York
F APPROV'A`L o, o �
t3� N S.C.T.M.: 1000-040.00-02.00-017.000
%
0 �~ �I I 10 0 0
s 0
n� \ L
vo ,- � � go ZO 0 SCALE:1"=30'
N69
pSE L� �tl Q "
//// �vOc° N NOTES:
s<s \ (S
1. AREA = 20,250 S.F.
2. ■ = MONUMENT FOUND, e = PIPE FOUND.
= STAKE SET.
p\ a <-- N0' osssW� `�- �I� , `� p�N MS��� ',` polo 7 3. SUBDIVISION MAP "EASTERN SHORES, SECTION 2"
FILED IN c� N�G gfDR RO
i\_\ q 9- U\ \--, �,o g `� ��� p o�GK pRogosto
�= COUNTY ONEAUOGFI IO,CE 01965 AS FIF THE RE NO. 4426.K OF LK
° 4. ELEVATIONS SHOWN HEREON ARE REFERENCED
145-\ �?, i TO APPROXIMATE N.A.V. DATUM (1988).
.0
CAD
\ \ DATE: JAN. 29, 2013
o -lam 06 \ O- JOB NO:2013-041
IS
CERTIFIED TO:
BRYAN VILLANTI
C
\ �Y,� E�g`$�
\ `�\\ /
TEST HOLE DATA �J \ 0.
FROM FILED MAP
TEST HOLE #2
EL=15.0 0.0
TOP SOIL
k LOAM w A
\ `�' \NC. \
� DAVID H. FOX, L.S. P.C. N.Y.SLS. #50234
3.0 O `Y1EV
\ / \A00
� -- FOX LAND SURVEYING
/ \ 64 SUNSET AVENUE
v
SAND do �,S0 \ WESTHAMPTON BEACH, N.Y. 11978
E\ °�ecl
GRAVEL (631) 288-0022
• �IPpb\��
UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY
IS A VIOLATION OFSECTION 7209 OF THE NEW YORK STATE
EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL
tEL�—1
W.
SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY
0 ———— 14.0
\\ z Ifr> b � CE TIFICATION INDICATED HEREON SHALL RUN ONLY TO THE
IIIVVV"' PE SON FOR WHOM THE SURVEY IS PREPARED AND ON HIS
Uu BE ALF TO THE TITLE COMPANY. GOVERNMENTAL AGENCY
<�1 OGO��I \ AS C EESNOF ITHE'ENDNGTION ISTED HEREON AND NSTITUTION. CERTIFIICATOIO SE
AR NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS
""� •7 Z4, OR UBSEOU ENT OWNERS.
DWG: 2013-041
TMRI
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