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Town Hall, 53095 Main Road
P.O. Box 1179
-420A,1 0
4 .,,�'/ Southold, New York 11971
JUDITH T.TERRY —. ,,,,#'�'�� FAx(516)765 1823
TOWN CLERK TELEPHONE(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. 1539-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JOHNSON, CARTON
Mailing Address 1 P. O. BOX 175
Mailing Address 2 BISBEE DRIVE
City St Zip SOUTH SALEM NY 10590-0000
Property Address 1 BAYV I EW DRIVE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2579
Tax Map No. section 37.00 block 5 lot 10.000
Cross Street OLD ORCHARD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • c��FF�(K�'-
Town of Southold � CQG� Application No. %5"3
Judith T. Terry, Town Clerk + f` L.%) $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 tri ` 'f , h�i ; $25.00 - Non-Residential
Southold, New York 11971 O ® " 0� is
Telephone 0? 'i "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ c) , ®®
DATE `�P� 2 19 9 0 -
`OWNER NAME: 13 a--n,., b INS o t�
OWNER MAILING ADDRESS: Bok �Qw d SAZenr� /U i1 0
OWNER PROPERTY ADDRESS: I LJ
OWNER TELEPHONE NUMBER: S J '�- 2_S '7
�- �� 9
TAX MAP NO. : Section 3`7 Block S Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: