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+.. 4* Town Hall, 53095 Main Road
-�` Vii` P.O. Box 1179
Cn, �j ��� Southold, New York 11971
JUDITH T.TERRY � ��r'�� FAx(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1033-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FOSTER, GEORGE A.
Mailing Address 1 BOX 896
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 BAYV I EW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3386
Tax Map No. section 78.00 block 2 lot 15.001
Cross Street BAYWATER AVENUE
Date Of Last Pump Out 0/00/81
Issue Date: 2/28/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
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OFFICE OF THE TOWN CLERK '0�FF00Q:- a
Town of Southold �� Application No. �� `3/
Judith T. Terry, Town Clerk 4t4;; .°r:N t
Town Hall, 53095 Main RoadT`''''`-- :'� Residential
p. O. Box 1179 to '- ; Non-Residential
Southold, New York 11971 O ®,.
Telephone -
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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.
Fee $ /0
•
DATE
OWNER NAME: CF6/2
OWNER MAILING ADDRESS: 80X g-
Zen J . V //a7
OWNER PROPERTY ADDRESS:
73•clyv ' Rc74r7
OWNER TELEPHONE NUMBER: 76-
TAX MAP NO. : Section Block Lot
CROSS STREET: 5-.7 ,41.4 1 j< CP-/'1e:.c.r74-2f /3c,-7
TYPE OF SYSTEM: Septic Tank i/ New Existing I/
Cesspool V' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
Yv�e
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.)
it
Si•;�atur of Applicant
RECEIVED BYgw, ,, • 1 •Ap
own CI/rk's Offi
DATE:
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