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O #1.A4‘JUDITH T. TERRY ` : Town Hall, 53095 Main Road
TOWN CLERK Z. O T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER 0` 0� Fax (516) 765-1823
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*' Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3139-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KING, ROSCOE
Mailing Address 1 BOX 193
Mailing Address 2
City St Zip ORIENT NY 11957-0193
Property Address 1 495 YOUNGS ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2611
Tax Map No. section 18.00 block 1 lot 8.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/26/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE• OF THE TOWN CLERKIC.��FFU(K '• •
Town of Southold � CQG Application No.c.373
Judith T. Terry, Town Clerk + P
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179cri f wit� i;< $25.00 - Non-Residential
A.
Southold, New York 11971 O "® - ®� ��
Telephone �('e Y► '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ fir. 0U
DATE (5 E , y' 1 q q3
OWNER NAME: le),.. e-ne /r
LT
OWNER MAILING ADDRESS: 4q 5 ��Q� �S �j r_ A k (1_3
NLY. - 0 , 4''3
OWNER PROPERTY ADDRESS: t q c(jD vc c
O ( J
v`e n fi i\L`r ( l g s 7
OWNER TELEPHONE NUMBER: CS-10
sJ0 .. I1
TAX MAP NO. : Section t g Block / Lot K
CROSS STREET: /'y) rf �(�p
TYPE OF SYSTEM: Septic Tank ✓ New e/ Existing
Cesspool New U Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: = ---- _!� be rP— LdeAtegasF
)4q3
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.)
01)-11 e— e
Signature of ApplWant
RECEIVED BY: �ccv_ ,�
Town Clerk'sOffice
DATE: A9-/ a/b.3
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