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Town Hall, 53095 Main Road
.*���, P.O. Box 1179
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,i•a, , Southold, New York 11971
JUDITH T.TERRY - �.,,,Aw r' 0FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1204-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HARNAN, EDNA TERRY
Mailing Address 1 MOORE MOSS, VIRGINIA B.
Mailing Address 2 P. O. BOX 1195
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1050 HYATT ROAD (EAST)
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2740
Tax Map No. section 50.00 block 1 lot 13.000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 0/00/83
Issue Date: 8/03/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.'-
OFFICE OF THE TOWN CLERK COFou,
Town of Southold Application No. J 2 .9
Judith T. Terry, Town Clerk ,� w .• ,
Town Hall, 53095 Main Road ' "`� .-( ' $10.00 - Residential
P. O. Box 1179 cr' .,� i ; $25.00 - Non-Residential
Southold, New York 11971 c;) ,
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Telephone j `A
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Gni 31, /cif 9
'OWNER NAME: al/A FERRY PAR AMY VVRGIA/44 .B, Me°1 I"go$ r
OWNER MAILING ADDRESS: P.a, 11�S
,S'ouT/Ndi ) AliY, /I971
OWNER PROPERTY ADDRESS:
lo5"a
1-1-1/41/A-7-7--�o ( -)
sof '77
OWNER TELEPHONE NUMBER: 574 – 74C— 7741O
TAX MAP NO. : Section 50 Block / Lot 13
CROSS STREET: ���� nn
...X(�111lVh UIEd-11Pv"t NUS ��o f ' .
TYPE OF SYSTEM: Septic Tank New Existing
CesspoolNew Existing 1,,,/Residential .� Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6 ic,pitm ,q ''"- kl
LOCATION MAP: Must be attached hereto before permit may be issued. - - N� °r
(Locate building and system; give north arrow and feet _
of distance, approximately, to building and closest road.)
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1,40 wr r XA�vc
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Signatu!-:ZI Applicant
RECEIVED BY: cc ), ' e_e¢,
Town/Clerk' Office
DATE:
AUG 0;
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