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JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK ® r�T� • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS tf'a .` Southold, New York 11971
MARRIAGE OFFICER Fax�' ��% Fax (516) 765-1823
= -41s.41 + ��® � 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. 2065-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HILTON, WILLIAM AND RITA
Mailing Address 1 1520 GRAND AVENUE -
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1520 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8789
Tax Map No. section 107.00 block 3 lot 11 .004
Cross Street BROWER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/04/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
V
OFFICE OF THE TOWN CLERK •c3\\FF0(,r
Town of Southold � ,,. CQ ' Application No. aOlos"?
Judith T. Terry, Town Clerk 144 y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 t' �; $25.00 - Non-Residential
Southold, New York 11971 u::•>*
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Telephone 0.( Nvoos•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ��• 0 CJ
DATE g 2.- 93
OWNER NAME: Gt/ILL/.497-i 4 R/cog
OWNER MAILING ADDRESS: `/7 -U Cf/''v/-i�
/` , l
i-7-7/76,6-e. / ,t K 1/ss-7---
OWNER
c5 —OWNER PROPERTY ADDRESS: 3/971-7_" - /IY,9 /5& "
OWNER TELEPHONE NUMBER: ,576 — '�� �7�5
TAX MAP NO. : Section / 07.00 Block 3, 06 Lot Gly. 0(-
CROSS STREET: Rot--t /2-i
•
TYPE OF SYSTEM: Septic Tank" i/ - - New Existing /57Y
Cesspool V New Existing J'iti c-i / S 7 Y
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.)
0 4 i�/M/i CJ%� ���G��r1r,/ U lv�(/i L�� vl ver
Signature of Applicant
(0-f/ � /-*,4-7✓ e//ti, 6'-7 J57 /1 6 2
RECEIVED BY:
Town Clerk's Office
DATE:
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•
.1
' TOWN OF SOUTHOLD
Ticket-No. 8 6 9 0
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1/ Lou
SCAVENGER WASTE REPORT o *'$
;_�,y�l ��p�,•• Fee: $.02 per gallon
�G I Fee $.c4-16- paid
Name of Hauler ✓d Date '�I4SZ'
•
paid
Permit Number /gyp , ' Southold Town Clerk
Truck Capacity ` C.) Gallons Liquid' Waste
Date Pumped a9/cia
Residential -1----" Commercial •
IRestaurant
0 SPLIT LOAD @ Gallons
Location:
Name of Owner. .
Street 45—c2e, 6-/`191144 I � 19L/Z
"�' Hamlet
Telephone Number, a 959' 87P/Tax Map Number /412,7",3" /2 V , '
• Cross Street
Diagram (locating building and, cesspool. Give north'.arrow and feet of 'distance,
approximately.)
. /
mouse
w o
Sep&`'c
•
I hereby certify that the above gineted within the Town of Southo
ld/Twn of Sheer
Island at the above location(s), and to the best of my knowledge, contains no h micals,
hazardous, or toxic wastes. False statements made herein are
punishable as a mis-
demeanor pursuant to Section 210-45 of the Penal Law of the State of New York, and
may result in my arrest and the impoj nd/ment ofIt e vehicle I am dri ing.
Name of Driver . ../ //t�'e t o./ ,a 4,
f Signature of Driver . re.
• Received by _ /
.`��?
Date . . ,�F',l7Q Time ,
(1) Treatment Plant ,