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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ®
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS &r6 �,�` 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. 1929-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MINER, GILBERT B.
Mailing Address 1 P. O. BOX 27
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1805 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3857
Tax Map No. section 60.00 block 1 lot 4.000
Cross Street HUMMEL AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK•
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Town of Southold �� - - CQG Application No. �?,,I-P
Judith T. Terry, Town Clerk � r
Town Hall, 53095 Main Road " kY",.'=_ '� $10.00 - Residential
P. O. Box 1179 u' ® .::
6"� "• ; $25.00 - Non-Residential
Southold, New York 11971 O '-a
Telephone #44�- � %6)-°9"
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: Gilbert B. Miner
OWNER MAILING ADDRESS: P. O. Box 27, Southold, NY 11971
OWNER PROPERTY ADDRESS: 1805 Youngs AvennP
Southold. NY 11971
OWNER TELEPHONE NUMBER: 765-3857
TAX MAP NO. : Section 60 Block 1 Lot 4 '-
CROSS
CROSS STREET: 3 , HummelAvenue
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.)
1>t s- l 060 . 11111r,d, C✓
Sig -tune of Applicant
•
RECEIVED BY: . _
Town Clerk's Office
DATE: - - r
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ScUTHOLD
SUFFOLK COUNTY N .Y.
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