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JUDITH T. TERRY ' ,.° �` ;z ,. Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ® ` '<= $ Iv
REGISTRAR OF VITAL STATISTICS grb
� Southold, New York 11971
MARRIAGE OFFICER . ® ,�1 Fax (516) 765-1823
_++ I 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. 1917-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FAUCON, HENRY AND DOROTHY
Mailing Address 1 P. O. BOX 602
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 46845 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2284
Tax Map No. section 69.00 block 5 lot 17.000
Cross Street SOUTH HARBOR ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�vFFUC,�.'- / 7-(
Town of Southold �� CQG' , Application No.
Judith T. Terry, Town Clerk
~ _° ,: .0 $10.00 - Residential
Town Hall, 53095 Main Road F
P. O. Box 1179 �V fin $25.00 - Non-Residential
Southold, New York 11971 O c '
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l0 •,7
DATE (-717-
OWNER
-7 OWNER NAME: //ens,/ et OrVt giaGDOWNER MAILING ADDRESS: (P-0 " / ox 6
N y 11 z/
OWNER PROPERTY ADDRESS: 7"6, F-44. $ Actin Rel.
- Ivy- i/ 77/
OWNER TELEPHONE NUMBER: 74- oa.a 8"-
_ TAX MAP NO. : Section i g Block 6— Lot
CROSS STREET: /Moil Pc-74, Rot
TYPE OF SYSTEM: Septic Tank s New Existing
et U + Cesspool New Existing
�l Residential Non-Residential
DATE OF PREVIOUS 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.)
2 go Nf"-
Signature of Applicant
RECEIVED BY:
- To 's Office
DATE:
Town Clerk Southard
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