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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK r� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS C11.2, � Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
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'!4 p b .r‘41 1111 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. 137-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner VAN DUZER APPLIANCE CO. INC.
Mailing Address 1 ROUTE 48
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 ROUTE 48
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3882
Tax Map No. section 55.00 block 2 lot 24.004
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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6OFFIcE;�OF THE TOWN CLERK - �FF0/1, ,V/2 /
Town of Southold ��� w ‘41 4, Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -� ti $10.00 — Residential
P. O. Box 1179 v' ' $25.00 - Non-Residential
Southold, New York 11971 O N
TelephoneJP ‘ttf
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: VA-fa /042 eye_ 4",e) •
Iii c� C� Ape4 1! FaLI�G
OWNER MAILING ADDRESS: nol f lig
Seq1C.40a, /VI 1/97/
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: 6`6 `7 s '"3 rgfa-
TAX MAP NO. : Section `j"6 Block O., Lot `I
CROSS STREET: yo�r.vys /4yE
TYPE OF SYSTEM: Septic Tank New Existing k
Cesspool New Existing ,
Residential Non-Residential -
DATE OFPREVIOUS PUMP-OUT:
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.)
•
04,-eAt
Signature of Applicant
RECEIVED BY:
Town Clerk's Office ,-
DATE:
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C.F. VAN DUZER, INC. .
ROUTE 48
P.O. BOX 1497
SOUTHOLD, NY 11971
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