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OFFICE OF THE TOWN CLERK 'cOF()
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ' , =- •
P. O. Box 1179 `v' ;n.F
Southold, New York 11971 •
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 167 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Almet R. Latson
OWNER MAILING ADDRESS: P.O. Box 1621
Southold, New York 11971
OWNER PROPERTY ADDRESS: 525 Town Creek Lane
Southold, New Yd rk 11971
OWNER TELEPHONE NUMBER: 516-765-3511
TAX MAP NO. : Section 64 Block 1 Lot 14.1
CROSS STREET: Youngs Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: October 22, 1986
Judith T. Terr
Southold Town Clerk
DATE: December 5, 1986
(TOWN' SEAL)
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cIFFICE OF THE TOWN CLERK so��F�(�.��=
Town of Southold • Application No. /6 7
Judith T. Terry, Town Clerk �`� R
Town Hall, 53095 Main Road o4 � Residential
P. O. Box 1179 U' ;
4 _ Non-Residential
Southold, New York 11971 - ‘r-
Telephone %-lgt •
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /C 7
Fee $ �-
DATE /'`"/e2/P-C
OWNER NAME: L.d1 7-- , L A-7-Sa IJ
OWNER MAILING ADDRESS: Po.. a. /I 4
S cry u rI4 m LAS 7.0f // 971
OWNER PROPERTY ADDRESS: 4C--/— l ori! I1, -f N a.
t,P '7+O /I // ,7f
OWNER TELEPHONE NUMBER: —6
TAX MAP NO. : Section Block Lot
CROSS STREET: 7()CO/Y , -l/�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /®`v`4
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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Signature of Applicant
RECEIVED BY: G ` ee..-� -, —
Town Qerk''s Office
OCRIVED
DATE:
DEC. ®5 ES
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