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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ®
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER i, Fax (516) 765-1823
Y r_�® 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. 2001-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SPARKE, WILLIAM H. & CLAIRE P.
Mailing Address 1 P. O. BOX 437
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 5430 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4509
Tax Map No. section 113.00 block 11 lot 19.000
Cross Street ILLINOIS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/28/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK ���FFO
Town of Southold d � ., CQG' Application No.o.k
Judith T. Terry, Town Clerk • =') $10.00 - Residential /��
Town Hall, 53095 Main Road «� ,
P. O. Box 1179 ntft. rf ;
$25.00 - Non-Residential
Southold, New York 11971 O 0 Y`* *-
Telephone j Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
`a v
Fee $
DATE C�C . I lqq-D-
OWNER NAME: Lk)1 L A-(v1 . - e
OWNER MAILING ADDRESS: T, 0. e).-clX
fY\pct-r--. � ���. iNJ Lit 1 I Q
OWNER PROPERTY ADDRESS: -BO O ‘4Q'L.c`:N- 111',0
N 1 1OWNER TELEPHONE NUMBER: ( �� ? -4o9
TAX MAP NO. : Section Block Lot
CROSS STREET: •
-
TYPE OF SYSTEM: Septic Tank X New Existing X
Cesspool New Existing X
Residential X Non-Residential C� j
DATE OF PREVIOUS PUMP-OUT: (N P-1 rpay' CT(NI ` I s f q21
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.) •
\
Sign,/of A,•plicant
RECEIVED BY:
Town Clerk's Office
MOVED
DATE:
OCT 2? 199? -
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--• I • L J�ry��� TO THIS SURVEY IS A VIOLATION OF
!ak : t" ! I-------, t 5• I�l i I SECTION 7209 OF THE NEW YORK STATE
tI Lb I ' I'�11'tU/J� r 1S.5�aU//\t:t� •36.0 CLL"V. ! EDUCATION LAW.
7 , ± ,0 `O 'r- r , '_ AT. ouT$.I Wt:5-T-COP-KM-K. or j^Re�igt:5: COPIES OF THIS SURVEY MAP NOT BEARING
I /�' f '(b '` �+ n 1 + THE LAND SURVEYOR'S INILLD SEAL OR
/�I i ' •LOT I�u/AML P..5 L.1 �•1(N �-t io I EMBOSSED SEAL SHALL NOT BE CONSIDERED
�' 4 , 1 amn., of Lore �T /t rTIT.)ct<,L..I- TO BE A VALID TRUE COPY.
Z � "‘ _ - PROYf- .TY of \V".t's.CotaLIr IQ " MLAO GUARAI TEES INDICATED HEREON SHALL RUN
_ ONLY TO 1H= rt. SDI,' FOR WHOM THE SURVEY
t �7 `‘. ��"• l IN Tt.t�SU)~�Ot,.l� GOI�+'JTY,CLEE=.t�' IS FREPAG[D, AND:J; H:S G.;IALF TO THE
tj,� r u or-F lC t^ /A�: P N1 S' T 5 !\h-t t7 TO TITLE COMPANY, G)VLRi:,b LN:AL AGENCY AN.
1 Ft �} Hm^r Cif-TOLL .Woan M FS LI�� /�S LENDI„G I.SY:IUEION LISTED H.I.LOn, AND
' i7 I TO THE ALB:,::LS OF EI;E LENDI'IG INSTI-
S0�•t ' ' /A� . Nr? 175• • TUTIO.� GUAI:ANIL:S A,• r:UT TRANSFERABLE
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