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JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK 6d® T , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS " $ Southold, New York 11971
�� Fax (516) 765-1823
MARRIAGE OFFICER ®
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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. 3179-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SMITH, RONALD AND ARLINE
Mailing Address 1 6320 MAIN BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 6320 MAIN BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-11003
Tax Map No. section 78.00 block 5 lot 7.000
Cross Street WATERVIEW DRIVE
Issue Date: 3/02/911 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�.\\MU• '�
Town of Southold ��Q ...•. •
�0�'• Application No. 3/71
Judith T. Terry, Town "Clerk` =y'°i y
�C I $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 u3 :=Y ; ' i $25.00 - Non-Residential
Southold, New York 11971
Telephone 0( ‘tt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2/7 .
Fee $
DATE 0/I(A-r2CH
OWNER NAME: o
OWNER MAILING ADDRESS: C.)) 2n In \ -eri) '-J Vt P-8A-p
OWNER PROPERTY ADDRESS: jt„,�� Aein�-
OWNER TELEPHONE NUMBER 51() '-jc- 1-0CD3
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
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.)
AO 1
JAIV
Signature of Applicant
RECEIVED BY: C9-2� �
Town Clerk's Office
DATE: a cG •
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