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K Town Hall, 53095 Main Road
' P.O. Box 1179
of
� �� Southold, New York 11971
JUDITH T.TERRY
-**---."4/ /�!�" TELEPHONE
TOWN CLERK < ��u���. (516)765-1801
REGISTRAR 01VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 926-R Residential X Non-Residential •
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PAYEN, BEATRICE
Mailing Address 1 P. O. BOX 789
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 225 HAYWATERS DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5361
Tax Map No. section 104.00 block 5 lot 18.000
Cross Street OAK DRIVE
Date Of Last Pump Out 0/00/78
Issue Date: 11/21/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
O*EICE OF THE TOWN CLERK cVFF001- ''
Town of Southold � 9c6
Dom �_, s ,�, QG Application No.
Judith T. Terry, Town Clerk Y�r; y
Town Hall, 53095 Main Road ' �'� x Residential
cn _-= �.
P. O. Box 1179 � �i � Non-Residential
Southold, New York 11971 OO ^ �Dyi�'`
Telephone = ,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
fur
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $lo,ob
DATE yt
OWNER NAME: 3,,d,„:„_ eon
OWNER MAILING ADDRESS: T. (:) .. 50-4, -\ (2 9
OWNER PROPERTY ADDRESS: , T_ q WATPRS -"\)R
C Lfr too G- e) 9
OWNER TELEPHONE NUMBER:
toot/
TAX MAP NO. : Section 1 y Block S Lot 1 t
CROSS STREET: (� �{ ` P. .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ti/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4*()-7c • q IJ.;, ‘IRS'.
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.)
-
Q
Signature of Appli ant
RECEIVED BY: D,be...2,0,6._
Town Clerk's Office
DATE: // 7-24 ��
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