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JUDITH T. TERRY cff '" Town Hall, 53095 Main Road
�' P.O. Box 1179
TOWN CLERK •
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REGISTRAR OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER � ® ~ Fax (516) 765 1823
__... �� �! Telephone (516) 765-1801
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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. 1904-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ` PUDGE CORP.
Mailing Address 1 P. 0. BOX 1465
Mailing Address 2.
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 605 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1850
Tax Map No. section 61 .00 block 4 lot 27.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK oc0FUUre,-
Town of Southold • �o Qli Application No. /M. '
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 - ® '** ' r` $25.00 - Non-Residential
Southold, New York 11971 O
Telephone 4074%
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,0 0
DATE 3/ /9
OWNER NAME: 1-C/C/p W/
OWNER MAILING ADDRESS: ,lea 1 6o( /.&6--
u>412 04, -21)/ //7.7/
OWNER PROPERTY ADDRESS: 6.(2
5
� 7 `��V
,p,m a (/ / //9,?/
OWNER TELEPHONE NUMBER: 576- 7G(` //v v
TAX MAP NO. : Section 6/ Block y Lot p??
CROSS STREET: c_ eer-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: A/07 XxiaCl,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.)
leJ /40/-9/ i4.. ,(2-y
Signature of Applica
RECEIVED BY: „
Town Clerk's Office
DATE: