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SJUDITH T.TERRY ��=1� G'f'A► Town Hall, 53095 Main Road
TOWN CLERK c3cto
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Q ,��, Southold,New York 11971
MARRIAGE OFFICER � �� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = ,( ais �a®���� Telephone(516) 765-1800
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. 3690-R Residential X Nor1-Residential
Fee $ 10.00 New Existing X
Name Of Owner SCOTT, ROBERT A.
Mailing Address 1 445 ALVAH'S LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935 0000
Property Address 1 445 ALVAH'S LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6415
Tax Map No. section 109.00 block 1 lot 30.000
Cross Street MAIN ROAD
Issue Date: 9/17/97 Judith . Terry
Southold wn Clerk
(TOW1 SEAL)
OFFICE OF THE TOWN CLERK �SVFFOC,(CQ
Town of Southold �� Application No. (1-0Judith T. Terry, Town Clerk �►�1
Town Hall, 53095 Main Road '" : I $10.00 - Residential
P. O. Box 1179 cn :
$25.00 - Non-Residential
Southold, New York 11971
Telephone .( , 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE C�f( 72
OWNER NAME: CriQv- 77)
OWNER MAILING ADDRESS: -S / t /700,�
OWNER PROPERTY ADDRESS: -c/9-)24
OWNER TELEPHONE NUMBER: _C-7‘"--•
TAX MAP NO. : Section / a 9' Block • I Lot - 0
CROSS STREET: i2277cv1c1
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool d 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.)
stgi
Signature of Applicant
RECEIVED BY: RECEIVED
Town Clerk's Office
DATE: SEP 16 1997
South!,id Town Clens
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