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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK - P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS -{ � ` Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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. 1589-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAYES, PAUL W. JR.
Mailing Address 1 P. O. BOX 158
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 625 BAYVIEW DRIVE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2953
Tax Map No. section 37.00 block 1 lot 21 .000
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
,bmer *ow
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OtFICE OF THE TOWN CLERK q\FFO(,(r .
Town of Southold � C'�G_ Application No. /sem
Judith T. Terry, Town Clerk :4; n . y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u' `' ` r =•.,y h�i ` $25.00 - Non-Residential
Southold, New York 11971 O `® :F J
Telephone 0.1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /•jj
• DATE Z() / OVetliSEe MD
'OWNER NAME: P.�I•UL W. /44163 ,)1Z. •
OWNER MAILING ADDRESS: p.Q . ox /53
Molizio \J � NV i!gi,3q
OWNER PROPERTY ADDRESS: 13.Avvie-k.)
MA/O t 0'37
OWNER TELEPHONE NUMBER: (51 0 y 77 —Z-953
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential >i Non-Residential
DATE OF PREVIOUS PUMP-OUT: jut'i /99O
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.)
z a/fdLL, .
Sig r ature of Applicant
RECEIVED BY:
Town Clerk's Office
-DATE:
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