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JUDITH T. TERRY ` ; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
cp'e Southold, New York 11971
• REGISTRAR OF VITAL STATISTICS = ‘Y® Fax Fax (516) 765-1823
MARRIAGE OFFICER =_-/� �® oe' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER _ O,j 4 r
FREEDOM OF INFORMATION OFFICER �� i,���'°.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL .
Operation Permit No. 3279-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HUKILL, W. PERRY
Mailing Address 1 12580 MAIN ROAD
Mailing Address 2
City St Zip EAST MARION NY. 11939-0000
Property Address 1 12580 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1465
Tax Map No. section 31 .00 block 14 lot 8.002
Cross Street 550' WEST OF DAM POND
Issue Date: 11/15/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i '
~OFFICE OF THE TOWN CLERK �� FFA
Town of Southold , O�oS� CQ =v Application No.,?77
Judith T. Terry, Town Clerk �►:\
Town Hall, 53095 Main Road , . I $10.00 - Residential
P. O. Box 1179 , - ► ;• $25.00 - Non-Residential -,
Southold, New York 11971 O . '• ' ': '',
Telephone 40 ��0 �•!
(516) '7 65-1801
TOWN OF SOUTHOLD ' '
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
0 .
APPLICATION
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OPERATION PERMIT
SEPTIC TANK`°oar EES 19 O L
so� i�g iOWn Cfeef�
Operation Permit No. __
Fee $
DATE '
OWNER NAME: W PE R X Hu K ( L L
OWNER MAILING ADDRESS: / ?,5-8-0 44/9//V FO/•,7D , ,
its r P7 rz(v.v , A/ /. //939 ,
OWNER PROPERTY ADDRESS: (57274/L
OWNER TELEPHONE NUMBER: 5-/6 c 77 /‘:6-C'
TAX MAP NO. : Section 3 / Block /V Lot R,;.R..,
CROSS STREET: 5 5 0ee- w.E DE/V cd /1i ���
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TYPE OF SYSTEM: Septic Tank New Existing
{ Cesspool New Existing
Residential �� 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.) • - .
///,Wc_.,,
Signa re of Applicant
- `
.671RECEIVED BY: I / '
T/owlerk's Office
DATE: 11 ' 6 1-71`
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