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OFFICE OF THE TOWN CLERK • •c�� FULic"
Town of Southold
Judith T. Terry, Town Clerk ` { '
Town Hall, 53095 Main Road -r
P. O. Box 1179 % carp
Southold, New York 11971 Q�l0N- •�
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 178 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Lawrence J. Hughes
OWNER MAILING ADDRESS: 7160 Horton I ane
Southold. New Yri'rk 11971
OWNER PROPERTY ADDRESS: 7160 Horton I ane
Southold, New York_
OWNER TELEPHONE NUMBER: 516-765-2748
• TAX MAP NO. : Section 54 Block 3 Lot 2,'
CROSS STREET: SoundView Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Te
Southold Town Clerk
DATE: December 15, 1986
(TOWN SEAL) J
I
OFFICE OF THE TOWN CLERK1FO
Town of Southold ���TM} CQG' Application No. /2L
Judith T. Terry, Town Clerk 4 c
Town Hall, 53095 Main Road ' 4
�c I Residential
X
P. O. Box 1179 1.11 t ,# ' �.` Non-Residential
Southold, New York 11971 ® o0O��J
Telephone .( '0
•
(516) 765-1801
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE - /J;?- / n:/
OWNER NAME: � " o�'`�"
r
OWNER MAILING ADDRESS: 2/ d c"4'
//7.71 747
OWNER PROPERTY ADDRESS: ---e-----01-1 � �--
OWNER TELEPHONE NUMBER: 7 b J Y717/ 1
TAX MAP NO. : Section ,S``7'/ Block C3 Lot /(72----/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool i/"/ New Existing
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.)
cat
Signatu of Applicant
RECEIVED BY:
Town/Clerk' Office
DATE: tt��
Iowa omit Southold
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