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GA 49
„ Town Hall, 53095 Main Road
� ' '' ��' P.O. Box 1179
® >®�i• Southold, New York 11971
JUDITH T.TERRY _®� 01,4°,1 TELEPHONE
TOWN CLERK i (516)765-1801
REGISTRAR OE VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 849-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner HAHN, ARTHUR W. III
Mailing Address 1 12 HONEY DRIVE
Mailing Address 2
City St Zip SYOSSET NY 11791-0000
Property Address 1 2295 BAYSHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-921-3126
Tax Map No. section 53 .00 block 4 lot 15. 000
Cross Street AUGUST LANE
Date Of Last Pump Out 0/00/00
Issue Date: 9/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
�� • „
OFFICE OF THE TOWN CLERK C�� Q(A' -
Town of Southold Q �� Application No. 1
Judith T. Terry, Town Clerky„ -
Town Hall, 53095 Main Road o Residential ✓
P. O. Box 1179 U-3 El*
tri , Non-Residential
Southold, New York 11971 O ®., 0���
Telephone Se/
(516)
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 13(-11
Fee $ 10 .00
DATE
OWNER NAME: �l� %/7 '4 W //&,/'v—�
OWNER MAILING ADDRESS: I2 ,9'e'4/A .>" :Q /
(51 /0,5597‘ -, /l/_ / / / 77/
OWNER PROPERTY ADDRESS: at 2 9'5- A57/3-6/0, g 40.
GAiF,g/I/?,,-> 4/y 11i74i
OWNER TELEPHONE NUMBER: .SIAS5- 707 'RfJ ‘'A&&A7A'//7 'f 77-e7 ,
TAX MAP NO. : Section -5-3 Block / Lot /3—
CROSS STREET: P/ GC/S 43e
,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing l/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: %/t 4z/f /3,9 /'04.
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
7,./;„( 7/".
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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