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Town Hall, 53095 Main Road
P.O. Box 1179
QQ c- `r44 Southold, New York 11971
JUDITH T.TERRY " �1 ° ��!`� FAX(516)765-1823
TOWN CLERK = < _.��z 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. 1320-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner HARRIS, BARNEY P.
Mailing Address 1 P. O. BOX 123
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 595 YOUNGS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8545
Tax Map No. section 1 . 14 block 10 lot 27
Cross Street WESTPHALIA AVENUE
Date Of Last Pump Out 1/01/88
Issue Date: 11/29/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•OFFICE OF THE TOWN CLERK S\\FFO(K�'`
Town of Southold � ._ C� '- Application No. 3 c B
Judith T. Terry, Town Clerk r r , �'� $10.00 - Residential
Town Hall, 53095 Main Road ; rk .
x� .
P. O. Box 1179 to - + r `
$25.00 - Non-Residential
Southold, New York 11971
-44&?:
Telephone - j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / (30V)
Fee $ /�� OD
DATE !//2�
OWNER NAME: AM/1/ 7/ /2 j r -R e/s • •
•
OWNER MAILING ADDRESS: Ra.do4- /2.) -- cls-7o(-4.14 i4tee
/71411.77.-E-A rJ 61f
_OWNER PROPERTY ADDRESS:
AES
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section If `/ Block 10 Lot 2.7
CROSS STREET: W )ja Q V per.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential "" Non-Residential
DATE OF PREVIOUS PUMP-OUT: (9• 1s"
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.)
/9154"4.4:A •
Signa ure of Applicant
RECEIVED BY: 4,40
To n C erk' Office
•
DATE: l/ 020/
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