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JUDITH T.TERRY Town Hall,53095 Main Road
TOWN CLERK c P.O.Box 1179
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,�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1 Fax(516)765-1823
MARRIAGE OFFICER ' jq4
RECORDS MANAGEMENT OFFICER _ � 0 ��osio 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. 3331-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner POULSON, JAMES H. AND RUTH E.
Mailing Address 1 750 CLEARVIEW AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 750 CLEARVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1824
Tax Map No. section 70.00 block 9 lot 61 .000
Cross Street BENNETS LANE
Issue Date: 5/16/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c0FO(,t �'
Town of Southold
Judith T. Terry, Town Clerk •� _ .,%,_ , Application No.
Town Hall, 53095 Main Road c '_:�=�� '-":;:_ -� 1 $10.00 - Residential
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P. O. Box 1179 crs R ";. y h�i •
Southold, New York 11971 :4''':'' '�••� $25.00 - Non-Residential
Telephone Q( ,� ��0''�•
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION R E CEl veo
for
AY , S /995
OPERATION PERMIT so Who'd �'® �
Clerk
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 579,5--
OWNER NAME: Jiffies H. 4. / u771 ,E, P®vZ. .S.,,/
OWNER MAILING ADDRESS: 75-a C L /5/q, V'/ aGJ //;=
saaro,o4. p, /1•/ /! 97/
OWNER PROPERTY ADDRESS: 251, �L,./1p )// 64.J M-y2
S TE,<'..)407 , /1/•y /( 97/
OWNER TELEPHONE NUMBER: 76,1-- /g2-
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TAX MAP NO. : Section 7C , Block 9 Lot 6 J
CROSS STREET: 34'44Y.Ais 4 44/4-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X.
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.)
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Signature of Applicant
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RECEIVED BY:
TownJerk's Office
DATE: 5'15-- 7s
11.1
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MSP OF PROPERTY
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j' �.., SECTION 7209 OF THE NEW YO
-a EDUCATION LAW, RK STATE
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