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JUDITH T. TERRY ® . Town Hall, 53095 Main Road
TOWN CLERK •
P.O. Box 1179
5:23
T ` Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � ih �
MARRIAGE OFFICER t. Fax (516) 765-1823
��®® - i;($1�' Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1792-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAWKINS, JOHN A.
Mailing Address 1 P. O. BOX 282
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1165 BRAY AVENUE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-8312
Tax Map No. section 126.00 block 8 lot 5.000
Cross Street FIFTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 10/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
CFFICE OF THE TOWN CLERK •c.31FDUI- -
Town of Southold CQ�; Application No. i , 9 a—
Judith T. Terry, Town Clerk ,0iiY
Town Hall, 53095 Main Road - $10.00 - Residential
p. O. Box 1179 ; .+ $25.00 - Non-Residential
Southold, New York 11971 O ®`' Y;
Telephone _o.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 77 7"'
Fee $ /0
DATE '� D 1 - 41
OWNER NAME: i' `�✓''L4
P4 ,OWNER MAILI G ADDRESS: L- i ,/,/ // .
�j�
OWNER PROPERTY ADDRESS: U.Q , ` fL;�k.-411'
OWNER TELEPHONE NUMBER: 427q.
TAX MAP NO. : Section fed 6 Block Lot 6—
CROSS
CROSS STREET: `"J
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �.' New Existing L�
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: /V C�.(.1 jr-
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.)
,IP a de,,,t,„2„44:4
Signature of Applicant
RECEIVED BY:
Town Clerk's'ffice
DATE: / O/ /jrf�
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