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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® , .� ,.';, P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �% Fax (516) 765-1823
MARRIAGE OFFICER Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ® 4111 ��0
FREEDOM OF INFORMATION OFFICER �
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 150-N Residential Non-Residential X
Fee $ 25.00 New Existing X
Name Of Owner PUDGE CORP.
Mailing Address 1 P. O. BOX 1465
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1040 HORTONS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1850
Tax Map No. section 63.00 block 1 lot 10.000
Cross Street TRAVELER STREET
Issue Date: 10/28/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
�= OI=FICE OF THE TOWN CLERK �r�� FF� /i '.
Town of Southold , % CQ _� Application No. /�
Judith T. Terry, Town Clerk
erk . , :• .
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 1179 tr3 `' $26.00 - Non-Residential
Southold, New York 11971 � ��`
Telephone 0.( * .� i
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for
OPERATION PERMIT
•
SEPTIC TANK or CESSPOOL •
Operation Permit-No.
Fee $ pUi00
•
DATEeY
•
OWNER NAME: 1 � D�� • •
OWNER MAILING ADDRESS: , )gOX / 4f
aM' /Ur ///y,
OWNER PROPERTY ADDRESS: /U � ) /2r.717s 449
J &'Mac/ ,vV // 7/
OWNER TELEPHONE NUMBER: S-"/&- 7&f- //if
TAX MAP NO. : Section clr 3 Block / Lot /6
CROSS STREET: ��6u,(4{ (/2.6.&74-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 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.)
14STrIa7ture of Appli nt
RECEIVED BY:
Town Clerk's Office
DATE: RECLINED
OCT 2 8 1994
sown Clerk Southold
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PO Box 19v-r
' MAIN ROAD
SOUT HOLD N.Y. 11971 R.E vis to," 2-4--