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JUDITH T.TERIIY4��� r� � 0:24,„
Town Hall, 53095 Main Road
TOWN CLERK .1%5 ; P.O. Box 1179
eY y P - 'f $ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
Fax(516) 765-1823
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MARRIAGE OFFICER �-44® �®��� Telephone (516) 765-1800
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3500-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HOYLE, TED
Mailing Address 1 P. O. BOX 1656
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 670 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3863
Tax Map No. section 64.00 block 1 lot 1 .000
Cross Street MAIN ROAD
Issue Date: 8/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 9c$FQ(��'%
Town of Southold �� CQG=� Application No. - at)
Judith T. Terry, Town Clerk , �-
Town Hall, 53095 Main Road $10.00 - Residential
p. O. Box 1179 �' hi ; $25.00 - Non-Residential
Southold, New York 11971 O ��`�
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Telephone '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
” DATE F-/hi—9L
OWNER NAME: --7"-Zi) {4011.-e
OWNER MAILING ADDRESS: "F.0. 134:04. 16910
. SooTkloLs, Ny 11`1)
OWNER PROPERTY ADDRESS: (.0 1 o You i•/5s Ave
?l17;
OWNER TELEPHONE NUMBER: Sb -?6S 3663
TAX MAP NO. : Section • Block —I - Lot
CROSS STREET: 4-Ae, Maw. 64,1 0I S 4vE
TYPE OF SYSTEM: Septic Tank ' ' New Existing rpt
Cesspool New Existing A
Residential K Non-Residential
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,.)
/
Signature f Applicant
RECEIVED BY: -
- Town Clerk's Office -
DATE: •
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