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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK
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T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2021-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHAW, ROBERT AND TERESA
Mailing Address 1 BOX 1145
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 9740 NEW SUFFOLK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5512
Tax Map No. section 116.00 block 5 lot 2.000
Cross Street DEAN DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 12/16/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK I��FFQ
Town of Southold .&%--•. �C� Application No. cA)oo?f
Judith T. Terry, Town Clerk ►�,
Town Hall, 53095 Main Road '�"` =s'>< $10.00 — Residential
' P. O. Box 1179 un 1 kZ, i $25.00 - Non-Residential
Southold, New York 11971
Telephone j y► '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE I ')'I gl 0 /
OWNER NAME: ((,b2 SIV,(4.,)
OWNER MAILING ADDRESS:
iv‘a."-Eti 49 WI
OWNER PROPERTY ADDRESS: LI 0 fle SkA.CA4rAg
n� r
OWNER TELEPHONE NUMBER: 7? �- SSI T—
J TAX MAP NO. : Section ) I le) Block Lot
- CROSS STREET: (,tom
TYPE .OF .SYSTEM:- - Septic-Tank New Existing r,/
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: r\) a.
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.)
Signature of Applicant
RECEIVED BY: pe
Town' Ierk's Office "
REMO
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DATE: - . . . _. _ . . _ . _ _ . _ ...,._
DEC T41992
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i UNAUTHORIZED ALTERATION OR ADDITION • -
1 TO THIS SURVEY IS A VIOLATION OF
SECTION 7269 OF THE NEW YORK STATE , . a
t v} 1 EDUCATION LAW- -
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Q2 - COPIES OF THIS SURVEY MAP NOT FEARING - - -- ---
1 J j THE SSD SU;.VEYOR'S INKED SEAL n V '�a�-{uL:�Y1 ��f i9 3 `
'1 i O 3 _ EMBOSSED SEAL-ShALL NO7 BE CO STIERFs 5 S�� 7 E'�
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5�� A9 ir' - _ Gt+A^ANTE:s :f�„+CA; NEON SHALL RUS9-. _ •
�J - ONLY TO 7HE'rc:SO;+FORT`l/OIA 7HE SURVEY - -- - -_ _- _
Ng t - IS PREPARED, AND ON HIS Bci-1ALF TO THE - . ( '�/ y
L 0 - - TITLE COMPANY, GO1 ERN:-NTA' AGENCY AND V ,,,_ y_ 3
1 - LENDING INSTITUTION LISTED H:REON,AND
IIt 7O THE ASSIGNEES OF Tris:LENDING INSTI; Lark/
l s `� a TUT+ON.GUARANTEES ARE NOT TRANSFERABLE L 1 Ca'r?'Gi La k/ St.:!'Vs21t i-y �'
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