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JUDITH T. TERRY ;T c-- t Town Hall, 53095 Main Road
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TOWN CLERK ,% tV P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ` ` . �a ;. r-H �` Southold, New York 11971
MARRIAGE OFFICER ,�� fr • Fax (516) 765-1823
0® �! Telephone (516) 765-1801
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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. 1900-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAELIN, FREDERICK AND MARGARET
Mailing Address 1 P.O. BOX 1
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 335 HIGHLAND ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7574
Tax Map No. section 109.00 block 2 lot 16.002
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 5/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFOL( 6706
Town of Southold �� _, %1 Application No.
Judith T. Terry, Town Clerk .f
Town Hall, 53095 Main Road -< $10.00 - Residential f"
P. O. Box 1179 to `_ ► $25.00 - Non-Residential
Southold, New York 11971 4 '® ` •,`
Telephone ®.(' 0 O
(516) 765-1801
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ M-1/0
1
DATE / y/9
OWNER NAME: FAR,onick, ria /.03 C47-4 74/44,16-1/0,— 16)74-4)
OWNER MAILING ADDRESS: ,fiU‘ #j//' /
GW/cid 6 t// j #01-
OWNER
/'OWNER PROPERTY ADDRESS: 3,73— f�IG=1��r��f/� /?i2
( TC M 6-tee-( ''V
OWNER TELEPHONE NUMBER: 5/4 " 75t/ 757,V
TAX MAP NO. : Section l o y Block /rg,_,, Lot,1-1-
/" P"
CROSS STREET: /671-
TYPE OF SYSTEM: Septic Tank .10 New Existing V
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: `( - et/
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.)
Signat re of Appli nt
RECEIVED BY: � n..9w10`'zJ
Town'Clerk's Office
DATE: WNW
MAY 131992
Town Clerk WV,
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