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SCLfTHCLD VIASTEVIATER d SPOSAL PERM T
CPERATI CN PERM T
SEPTI C TANG or CESSPOCL
Cper at i on Per M t M. 4461-R Rlesi dent i al X Nbn-Rlesi dent i al
Fee $ 10. 00 New X Exi st i ng
Kane Cf Ower ARNIMD & C-ERALDI NE 6ARTCN
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Nbi I i ng Address 1 100 H LTCN M EIS 210E
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Nbi I i ng Address 2
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0 t y St Zi p CEN CI TY NY 11530-0000
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Pr oper t y Address 1 1850 COLITRY CUB DRI VE
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Pr oper t y Address 2
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Ci t y St Zip CUTCHOQE NY 11935-0000
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Ower Telephone Nb. 516-742-2814
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Tax MAp M. sect i on 109. 00 block 3 1 of 2. 019
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Cr oss St r eet MDO;E S LANE
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I ssue Date: 4/ 14/ 14 D i zabet h A Nevi I I e
-------- Southol d Town a erk
(TOIN SEAL)
o�osuFFot�.�oG
ELIZABETH A. NEVILLE co y Town Hall, 53095 Main Road
TOWN CLERK ce = P.O. Box 1179
REGISTRAR.OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER '1ifJ • ��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �l �a 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
Residential @ $10�or Non-Residential @$25 Application No.
Permit No. 4
Owner Name s�
Owner Mailing Address C25�' Vh -W►J Ave. ) Q-10 C
ceM2OG"A a-- -1 , �-4 Y 1 53 0
Owner Property Address «� 6P4WIV:Z�4 CA_A� L;>VZtAjf��-.
Owner Telephone No.
Tax Map No: Section Block Lot 2
Cross Street L hJ r)%a j ► M azo Y `5 L�1��
Please check each that applies: New Construction
Alteration to Existing System X
Residential. X_ —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.)
i
Sig4ature of Applicant Date
Received by:
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S.C.D.H.S. REFERENCE NUMBER R10-13-0015
LOT NUMBERS REFER TO "MAP OF COUNTRY CLUB SURVEY OF PROPERTY
ESTATES" FILED IN THE SUFFOLK COUNTY CLERK'S AT CUTCHOGVE
N OFFICE ON OCTOBER 17, 1978 AS FILE NO. 6736. 0 THOLD
TOWN OF S U
SUFFOLK COUNTY, X Y.
1000-109-03-2.19 I
SCALE.- 1'--30'
JANUARY 21, 2014
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LOT 15
LOT 16
LOT 17
-nuTy 162.35 41 SOF EleyBox
S82'53 40 W
co�. - 7 80. FT.
LOCATION OF SEPTIC SYSTEM FROM OTHERS. 4,` N.Y.S. LIC. NO. 49618
`ANY AL7ERA77ON OR ADDI77ON TO THIS SURVEY IS A VIOLATION , qct! lC EYORS, P.C.
OF SEC77ON 7209OF THE NEW YORK STA 7E EDUCA77ON LAW. 765-5020 FAX (631) 765-1797
EXCEPT AS PER SECTION 7209—SUBDIVISION 2. ALL CERTIFICATIONS LAIVF3 0 BOX 909
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF
SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF 7NE SURVEYOR 1230 TRAVELER STREET
WHOSE SIGNATURE APPEARS HEREON. 0:=M ON U MEN T SOU THOLD, N. Y. 11971 84-113