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JUDITH T.TERRY , ® ,.r:= Town Hall,53095 Main Road
TOWN CLERK chi a„> P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER de*® �ZV` hone(516)765-1800
set Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER e `D '�� Telephone
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. 3249-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MILLER, ROBERT
Mailing Address 1 1560 BAY HAVEN LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1560 BAY HAVEN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1562
Tax Map No. section 88.00 block 4 lot 15.000
Cross Street MAIN BAYV I EW ROAD
Issue Date: 9/08/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 5�FF0(,(
Town of Southold Q� CQG=� Application No. 3Q (/7
Judith T. Terry, Town Clerk .` - y:�
Town Hall, 53095 Main Road -� $10.00 - Residential
P. 0. Box 1179 • cn ; $25.00 - Non-Residential
Southold, New York 11971 0 •�`
Telephone �j 31( " ole
(516) 765-1801
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TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE � �� 5�c
' OWNER NAME: ;� o f lr� �.\ '-L
OWNER MAILING ADDRESS: t `� C� O ►J (�� �� b
vt�\ 01-0 ) W - wzc
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: '7 6, c
TAX MAP NO. : Section /
� Block '`� Lot / •C
CROSS STREET: / f c
TYPE OF SYSTEM: Septic Tank r/ New Existing V
Cesspool New Existing
• Residential Non-Residential
- I
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.)
• Signature of Applicant
RECEIVED BY: Ljtj/a -
Town
(y Clerk's Office
DATE: 7 �� � �? y
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