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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK 0-v-11„ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .�`' Southold, New York 11971
MARRIAGE OFFICER 1 1� Fax (516) 765-1823
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® �� 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. 1995-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAELIN, MARY A.
Mailing Address 1 P. O. BOX 13
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4300 DEPOT LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6176
Tax Map No. section 95.00 block 5 lot 9.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/89
Issue Date: 10/20/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FD(,' -
Town of Southold0�� �;, r_ ��CQG'` Application No. /'9 es -'
Judith T. Terry, Town Clerk „�, .
Town Hall, 53095 Main Road ~ -� 1 , $10.00 - Residential
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P. O. Box 1179 Y� r r;• ► � $25.00 - Non-Residential •
Southold, New York 11971 � r �0�1�`
Telephone : j y4 '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /996
Fee $ l0
DATE
•
OWNER NAME: \\N\ !� � \'\ \1
OWNER MAILING ADDRESS:L-_t,tb �\
OWNER PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER: \k� -z \"\
TAX MAP NO. : Section / 5- Block 5 Lot
` CROSS STREET: P, •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �j New Existing s,-
Residential ./ Non-Residential
DATE OF PREVIOUS PUMP-OUT: l 9 Of
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.)
‘nature of Applicant
RECEIVED BY: Di/
Town Clerk's •ffice
DATE: /
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