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JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK r-rt P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS • �� Southold, New York 11971
MARRIAGE OFFICER -�®�� �' ,l Fax (516) 765-1823
®1 Ma 11%. Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3029-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner DALTON, WILLIAM
Mailing Address 1 120 HUNTINGTON BAY ROAD
Mailing Address 2
City St Zip HUNTINGTON NY 11743-0000
Property Address 1 725 HOLDEN AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-271-5238
Tax Map No. section 110.00 block 5 lot 50.000
Cross Street SOUTHERN CROSS
Date Of Last Pump Out 0/00/00
Issue Date: 5/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •SWFO(A-�'=
Town of Southold � r& I" Application No. 3005
Judith T. Terry, Town Clerk
t , .c 4 < ! $10.00 - Residential
Town Hall, 53095 Main Road c � � .
p. O. Box 1179 u' $25.00 - Non-Residential
Southold, New York 11971
Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /6
DATE ......0S/F3
OWNER NAME: 11\t,v i
OWNER MAILING ADDRESS: A9-0 / r ,, _,,� p
/4. yp� �A), //7°K3
OWNER PROPERTY ADDRESS:--to 6-0 6-5 170 l6e,AJ he %oo o r7 �a� rYJ
".„4/6,40 eve- C' 6t1 v e_ ti /C?:S'
OWNER TELEPHONE NUMBER: 7l ' <5;1-3
TAX MAP NO. : Section i(0 Block Lot �C.)
CROSS STREET:- �ovVerni C/1o5,S
yJ�
TYPE OF SYSTEM: __"Septic Tank%a 61(/uJ New <„,„...- Existing
•Cesspool /-0046-i- 0,,a7 New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: '
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
S ,_ of distance, approximately, to building and closest road,)
/ 493(74
,
_.__.,/- I
ignature of App icant
RECEIVED BY: C�r�
TownClerk s Office
DATE:
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THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD,IF ANY,NOT SHOWN ARE NOT GUARANTEED. ••
THIS SURVEY WAS PREPARED IN ACCORDANCE WITH THE EXISTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE'NEW YORK STATE
ASSOCIATION OF PROFESSIONAL LAND SURVEYORS.
UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 SUBDIVISION 2 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 VALID TRUE
• COPY.CERTIFICATIONS 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 HFRFnN•ND Tn THE acc Iruccc nc TUE I curnur.ruCmm,Irtnu rCOTtEtr•nn►ie