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Town Hall, 53095 Main Road
•4‘1, ® P.O. Box 1179
ss22 ,sfir Southold, New York 11971
JUDITH T.TERRY �� tLs' TELEPHONE
TOWN CLERK " (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. 3671-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HORTON CURTIS WILLIAM
Mailing Address 1 1835 MASON DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1835 MASON DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6371
Tax Map No. section 104.00 block 6 lot 15.000
Cross Street
Issue Date: 8/08/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFI.tE OF THE TOWN CLERK •cv�FUCA. . ((—
Town of Southold &% Cil-%. Application No 3(0
Judith T. Terry, Town Clerk
Town Hall, 53095 Main RoadI $10.00 - Residential
P. O. Box 1179 tri "�;' $25.00 - Non-Residential
Southold, New York 11971 O �`
Telephone _Old 0 "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for ---- --------
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / 7d
Fee $ / 0 , 0a
DATE & c 49,7
OWNER NAME: ..i u�r ><i LAip,•J
OWNER MAILING ADDRESS: 1 83, ! •
OWNER PROPERTY ADDRESS: 4. ,
OWNER TELEPHONE NUMBER: 73 y �� 3 7/
TAX MAP NO. : Section / Q 9 Block Lot IS--
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing
Residential Non-Residential
LOCATION MAP: Must e a ac - . - - • - - : - _ ••• z - '
a/� �/L. �� . _: - . .' _ - _ • - - .,
, _ - • .' . . and clo oad.
COf)sr/fiL T # /70y
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47
Signature of • pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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