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JUDITH T. TERRY ; < Town Hall, 53095 Main Road
TOWN CLERK ® P O. Box 1179
$ REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
��® r�� 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. 1756-R Residential X Non-Residential
Fee $ 10.06 Septic Cesspool X
New Existing X
Name Of Owner KYLE, KEVIN C. AND ASCENSION
Mailing Address 1 1830 BOISSEAU AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1830 BOISSEAU AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1715
Tax Map No. section 55.00 block 6 lot 18.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 9/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK VFFOU( -
Town of SoutholdgrA
� CQG' Application 'No. /75
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a -04-• y,'; -'� I $10.00 - Residential
P. O. Box 1179 t :~ �;
$25.00 - Non-Residential
*dike
Southold, New York 11971 O :° r �0���`
Telephone = (
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /756
Fee $ DC7 , (3a
DATE qI 1 9 )
OWNER NAME: cvll\ G (Ind AScens ion
OWNER MAILING ADDRESS: 1 Bo gOl s5e Q L, A\)€- '
SotA.--1--h of oP , 9i I
- OWNER PROPERTY ADDRESS: Salvl.e,
OWNER TELEPHONE NUMBER: "j (.0 - L t L 5
TAX MAP NO. : Section 5.5 Block (p - Lot 7 B
CROSS STREET: Ke
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: x
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.)
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VAti;t' 1
Signature of .plicant
RECEIVED BY: .;,,g�..
TownigClerk'�fice '
DATE: ROM
SEP 181991
Ion GM SAW
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