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JUDITH T. TERRY �G Town Hall, 53095 Main Road
TOWN CLERK P.O.►�T Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER 'Y® 0� �,
- �yFax (516) 765-1823ol + -1Drr rr� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3028-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner QUALEY, ELIZABETH
Mailing Address 1 BOX 246
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 395 ALBO DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5259
Tax Map No. section 126.00 block 2 lot 10.002
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�vFFD(,��'-
Town of Southold � 0 % , Application No. d�--
Judith T. Terry, Town Clerk � � ��' $10.00'- Residential
Town Hall, 53095 Main Road
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P. O. Box 1179 A ;y � $25.00 - Non-Residential
Southold, New York 11971
Telephone ®(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 106°
DATE M19 177 ( a 3
OWNER NAME: IIZO.,I9i9 )i{ a (
OWNER MAILING ADDRESS: `13 0.1 . 246 - ,3? G- /-LeQ Div
Lo u rat 14ff. / /9g
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: J-q S 2
TAX MAP NO. : Section M 4P Block Lot `01
CROSS STREET: VcLQ4 C �-
TY-PE 50F 'SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing 1/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
alkAisaltizt
ignature of Applica`
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RECEIVED'BY:
Town Clerk's Office
DATE:
/7OWNER:
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SUFF.CO-HEALTH DEPT.APPROVAL H.S. NO.
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:.fes �) SECTION 72C9 OF The NEW YORK STATE
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TITLE TITLE CC,.I;AI. , ,,;,',L:,•,;,::. AL AGENCY AN
CERTIF. 1 LEND:kG , TL;:J:I _IS:E.C..y.LON,AND
TO IhE ASS C„L;S OF T,IL LENDING:INSTF-
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TO ADD:TIUNAL Ih:SfITUiION
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LIC. LAND.SURVEYORS-GREEN-PORT. N. Y.
TEST HOLE SUFE CO. DEPT, OF HEALTH SERVICES t i
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STATEMENT OF INTENT
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6FOR APPROVAL OF CONSTRUCTION ONLY
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THE WATER SUPPLY AND SEWAGE
DATE:
DISPOSAL SYSTEMS FOR THIS RESI-
rr DENCE WILL CONFORM TO THE ”
C:rl..r.: H.S. REF. NO.: �`� ,�C.L� % '�// ''f
STANDARDS OF SUFFOLK CO. DEPT,
OF HEALTH. SERVICES. •-
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