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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK rrri P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER `yQ •,� Fax (516) 765-1823
- Ol �o 1� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3171-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LATHAM, BETSY
Mailing Address 1 195 POINT ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 195 POINT ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2675 4,
V--
---Tax Map No. section 15.00 block lot
Cross Street ROUTE 25
Issue Date: 2/04/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�VFFO(,r
Town of Southold ®�� r CQ ', Application No.
Judith T. Terry, Town Clerk . k �►`
Town Hall, 53095 Main Road '� $10.00 - Residential
• P. O. Box 1179 v' •. f%:s' hi
Gr . $25.00 - Non-Residential
Southold, New York 11971 O ® °= • Nt'�•••�
Telephone Q(5 '°;'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APs LCAT!Oi
for ir„ 1VP'
OPERATION PERMIT JAN 3 1 1994
SEPTIC TANK or CESSPOOL a 04)040 Tamen I(r
Operation Permit No.
Fee $
DATE Fes,_- ufiR/ /, I 7? `L
OWNER NAME: J Q 173 y ±h r1
OWNER MAILING ADDRESS: / 9 -5- fo Nfi R
Aye' ,/ l // 93-7
OWNER PROPERTY ADDRESS: SAi,i /IS /9/3oUe—
OWNER TELEPHONE NUMBER: L3a3 - c ( a7
TAX MAP NO. : Section / Block — ( Lot-16 ' 1,3
CROSS STREET: R‹ g, 5-- Q ►uL pe!NT P
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t/ New Existing
Residential Non-Residential
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.)
, 40
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Si.' ature of A.plicant
RECEIVED BY: ),tea �
Town )erk's Office
DATE: J, r , c
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