HomeMy WebLinkAboutBondarchuk (2) SCUTHCLD VASTEVIATER d SPCGAL PERM T
CPERATI CN PERM T
SEPTI C TANK or CESSPOCL
Oper at i on Per rri t No. 4495-R %si dent i al X Non-Resi dent i al
Fee $ 10. 00 New Exi st i ng X
Name Cf OAner EDVWU J.
------------------------------
Wi I i ng Address 1 650 BLUE KARLI N DRI VE
------------------------------
Mai I i ng Address 2
------------------------------
O t y St Zi p SCUTHCL.D W 11971-0000
-------------------- -- ----------
Pr oper t y Addr ess 1 650 BLUE MVU N DRI VE
------------------------------
Pr oper t y Addr ess 2
------------------------------
0 t y St Zi p SCUTHCLD W 11971-0000
-------------------- -- ----------
Owner Telephone W. 000-000-0000
------------
Tax Map W. sect i on 57. 00 block 1 1 of 28. 000
------ --- ------
Or oss St r eet ALBACCRE DRI VE
------------------------------
------------- --------------------
I
---------------------------------------------------------------
I ssue Date: 8/30/ 16 D i zabet h A Wvi I I e
-------- Sout hol d Town a erk
(TOIN SEAL)
SUFF04C�G
ELIZABETH A. NEVILLE O y� Town Hall, 53095 Main Road
TOWN CLERK H Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICSO Southold, New York 11971
MARRIAGE OFFICER y ' �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �Ol `�►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
Li Li
Residential @ $10--A or Non-Residential @$25 Application No. J
Permit No.
Owner Name &I wlgrd -IT B)(%iRrCr X)L
Owner Mailing Address_ oUlnRIin� D-) V—Q.
(4kuid oy 0/i/
Owner Property Address 6S0 V U.�Q /n9/l,n �i c%P
Owner Telephone No.
Tax Map No: /000 Section �50 Block 0 / Lot � -
Cross Street 69;-002
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 Applicant Date
Received by:
v /
}
�• N
n t E o NOTES:
1. ELEVATIONS ARE REFERENCED TO N.G.V.D. 11
/ 1 • ,. I g \ OJ D( FNW
F 1I TIONS ARE SHOWN THUS:
WAKE FUM
4 \ 2. FLOOD ZONE INFORMATION TAKEN FROM:
FLOOD INSURANCE RATE MAP No. 36103COV
1 •d
� ZONE YE: COASTAL FLED WffH VELOCITY tU+71
BASE FLOOD ELEVATIONS DETERMINE
Voir - �I \ ZONE X': AREAS OF 0.27E ANNUAL CHANCE FL
cn +. WITH AVERAGE DEPTN OF LESS THM
\ I \ 1 SQUARE MILE: AND AREAS PROTIX
ZONE X. AREAS DETERMINED TO BE OUTSIDE T
a
ea 6
Q
S' 70p CA '
DP 1 101
� H
SUIF
A7
s�s 9.o w ` .I, �V T
v` L
O 1 SjGR`l GARp,GE
N N0 �s e
.56 SOUTHO
�m a. TIN,*c FILE No. 3853
SIT'
ig �z3
ARSE
iE1X� $ $ \\N N TOWN C
ZpNE \ w SUFFOLK CC
\\ a S.C. TAX No
sc�
w\0- 1h ' \ Jur
N
JANUARY 30
FZBRUARY 10, 2015 ADD
co j8 AREA =
P.. (TO BULKHEAD)
��K 0.r � �o o��• e� �] ��
o9+gyp SD
5
CERTIFIED T0:
EDWARD J. BOND)
r%nmUnNWFAI TH L