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OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 16 Residential X
Fee $ 10. 00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Philip H. Koch
OWNER MAILING ADDRESS: Box 41 , 600 Bay Avenue
East Marion, NY 11939
OWNER PROPERTY ADDRESS: 600 Bay Avenue
East Marion, NY 11939
OWNER TELEPHONE NUMBER: 477-2537
' TAX MAP NO. : Section 31 Block 8 , Lot 10
CROSS STREET: Marion Lane
- TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 20 , 1986
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Judith T. Terry
Southold Town Clerk
DATE: August 18, 1986
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,OFrIICE OF THE TOWN CLERK c0FD
Town of SoutholdCSG
Application No. /
Judith T. Terry, Town Clerk x5 11';
Town Hall, 53095 Main Road o N • 4 ' Residential (/
P. O. Box 1179 5' = : Non-Residential
Southold, New York 11971 � ® `T �'�
Telephone (1 [ It
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /6
Fee $ 0
DATE 7– (7" ZC
OWNER NAME: 4' /12/67/4. / / A,'. /1/0 /7/.
OWNER MAILING ADDRESS: A9--N_ =0 (c 64 !
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OWNER PROPERTY ADDRESS: /- tf3 ,4-S 4--T3 leg.
OWNER TELEPHONE NUMBER: .57C '177— &537
TAX MAP NO. : Section 3l Block e54. Lot /O
CROSS STREET: Oeft 0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool !/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ?-- go, $ 3
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.)
Sig ature of Applicant
RECEIVED BY: Lax—ci•
TownClerk Of ce
DATE: ca., /1, /1 [o
RENSSELAER G. TERRY, Jr a7.) ` 2 0 E - ') L4' - — J I
ATTORNEY - AT - LAW J _
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