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JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ® g.
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER
VOA, O X•41' Fax (516) 765-1823
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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. 1972-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAYSER, PAUL AND MARGARET
Mailing Address 1 1005 MILL CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1005 MILL CREEK DIRVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1699
Tax Map No. section 135.00 block 3 lot 39.000
Cross Street GROVE DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 9/21/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c0FO(,r �
Town of Southold , Y>. •CS'G-_ Application No.
Judith T. Terry, Town Clerk Tr y
Town Hall, 53095 Main Road e.„.1%. $10.00 - Residential
p. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971
Telephone = j * `�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0;,0b
DATE "b7)? )--
,
OWNER NAME: C7�Cr ,2..
OWNER MAILING ADDRESS: ' 100S !tit L. L. Ci &L) ' B /6
OWNER PROPERTY ADDRESS: fc-o
OWNER TELEPHONE NUMBER: L/4® WY' /4 9,
TAX MAP NO. : Section /57� Block d 3 Lot 3
"CROSS STREET:
TYPE: OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: RA'
• I
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.)
'Signatu of Applicant
RECEIVED BY_:- - - _ .
Town Clerk's Office
DATE: - - - -
Paul W. Kayser, FIC
District Representative
1005 Mill Creek Drive
LlJll-IERAN Southold,New York 11971
E.;A! Bus: (516)273-9688
o BRO11-IERHOOD Res: (516)765-1699
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Representative,LUTHERAN BROTHERHOOD SECURITIES CORP.,625 Fourth Avenue South,Minneap•lis,MN 55415