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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4364-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WILLIAM & CATHERINE GLADITSCH
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Mailing Address 1 3664 COLLECTOR LANE
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Mailing Address 2
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City St Zip BETHPAGE NY 11714-0000
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Property Address 1 550 BAILIE BEACH ROAD
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Property Address 2
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City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-579-5888
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Tax Map No. section 99.00 block 3 lot 413
Cross Street SOUNDVIEW AVENUE
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Issue Date: 12/06/07 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE �`Z` G.y Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
GO Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS v.
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER O'� �a southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 V r Non-Residential @ $25 Application No. L6109
Permit No. 3 13 5
Owner Name C 4-h P r ► e C 1 ad , 4 S c
Owner Mailing Address r (o to l� c o I 1 e o +o r �_ Q n e
Owner Property Address �J� 50 80- 1 ] 1 e (3 e Ck C 1'1 Q,J
H k + + + UCk
Owner Telephone No. 61 (o 5 0 9 �5_
Tax Map No4Q39 Section Block Q o O Lot 0 O L4
Cross Street U n d U i -e E j rY1 t/e
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 approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Signature of pplicant Date
Received by:
11111!,!111 II,VVfUl N I I I IIIII IIIIIIIIIII III
Survey for:
WILLIAM GLADI TSCH , &
P�eo e Sty,FOUK COU1,07Y DER S M AENIT OF HEALTH SERVICES C THERINE CLADI T SCH
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Jed 12500 FosE f�N�E ��n OR
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Rese NPN�,NK _ _. Lot 13, "Honeysuckle Hills"
Nov 2 At
Mattituck
a0 } 4 E ` ix Town of
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�,. Southold
Suffolk County, New York
\\\ LOQ �� s S.C.T.M.: 1000-099.00-b3.00-004.013
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N \\ � 1 SCALE:1"=30'
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a PRP o O 1. AREA = 25,000 S.F.
P
t\\ Sja,E ,, Z 2. ■ = MONUMENT FOUND. L = STAKE FOUND,
O= SPIKE SET, = STAKE SET.
\\\ Ppm ,,-'A2 3. SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK
P. L OF SUFFOLK COUNTY ON OCT. 16, 1981 AS FILE NO. 7019.
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OCT.MAY 2 5 N
2004 F OU LSUR
LOCATION ,
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2i 'a j R l MAR. 6, 2004 srx.FOR CONSTR11mm
6 OCT. 25. 2002 AMENDED CERTIFICATION
�dt�FGpc,E SEPT. 10, 2002 ADDED CERTIFICATION
Z s C DATE: SEPT. 05, 2002
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JOB NO:2002-441
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CERTIFIED TO:
w01401 i ' k612 WILLIAM GLADITSCH
0j. CATHERINE GLADITSCH
COMMONWEALTH LAND TITLE
Rene $gyp`N INSURANCE COMPANY
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DAVID H. FOX L.S. P.C. N.Y.S.L.S. #50234
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FOX AND SUAWINC
.1a3 PP Q• 64 SUNSET AVENUE
Eos ¢ �` WESTHAMPTON MACH. N.Y. 11978
00 (631) 288-0022
UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY
�G IS A VIOLATION OFSECTON7209 OF THE NEW YORK STATE
EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL
SHALL NOT BE CONSIDERED TO BE A VAUD TRUE COPY.
CERTIFICATION INDICATED HEREON SHALL RUN ONLY TO THE
` - PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS
BEHALF TO THE TITLE COMPANY. GOVERNMENTAL AGENCY
AND LENDING INSTITUTION LISTED HEREON . AND TO THE
ASSIGNEES OF THE LENDING INSTITUTION. CERTIFICATIONS
ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS
OR SUBSEQUENT OWNERS.
DWG: 2002-441