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JUDITH T. TERRY ' < Town Hall, 53095 Main Road
TOWN CLERKT P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 6� aC • Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
� ' Telephone (516) 765-1801
11*OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1653-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HILDEBRANDT, WALTER
Mailing Address 1 1555 BROADWATERS ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1555 BROADWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5033
Tax Map No. section 104.00 block 11 lot 4.000
Cross Street HAYWATERS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11.108/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN Q ERK c�vFFOCR-
Tow n of Southold - ----
Judith
C'� Application No./625 -3
Judith T. Terry, Town Clerk . . . `:„ 4 -►
Town Hall, 53095 Main Road � :� } $10.00 - Residential
P. O. Box 1179 v' "pm $25.00 - Non-Residential
Southold, New York 11971 O , _OJ
•
Telephone !.;5"0/414-
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3/i /7/
OWNER NAME: 62,...) /4-1- T& I /d D f 14 i # JlD'T
OWNER MAILING ADDRESS: /..6.67-6- J3RO W417a R S 804(4-P
C 7 c. +I 0 & d,C r I! ' 3,5-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 739 - __C® 3.3
TAX MAP NO. : Section J 0 11 Block /1 Lot A/
CROSS STREET: /44- 5/46/ ROA-L)
TYPE
OA-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing L
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
6t)ajt , i 4/ it
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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