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JUDITH T. TERRY it It Town Hall, 53095 Main Road
TOW10T CLERK : v Fn P.O. Box 1179
cl' � Southold, New York 11971
, REGISTRAR OF VITAL STATISTICS VO ��� Fax (516) 765-1823
MARRIAGE OFFICER ' '' ® t!� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER i�
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. 3163-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner TUTHILL, LYLE AND RUTH
Mailing Address 1 P. O. BOX 192
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 21505 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3550
Tax Map No. section 17.00 block 4 lot 16.000
Cross Street OYSTERPONDS LANE
Issue Date: 1/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold &\) „�. GQ," Application No.
Judith T. Terry, Town Clerk .' ,;, `:y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 crs ` "^: ' n $25.00 - Non-Residential
Southold, New York 11971 •`' O�•'`
Telephone j if(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE t
OWNER NAME: 7-14'ki' I )
OWNER MAILING ADDRESS: 1131,0, J> irQh.N.111 ) 167
OWNER PROPERTY ADDRESS: a v5 Qrj Ake (Q4.
OWNER TELEPHONE NUMBER: ,A r f 3 3 — , 3 S ?)
TAX MAP NO. : Section t '7 Block l Lot 1 C, a a
CROSS STREET: tAA- p int pd L A.A.)
TYPE OF SYSTEM: Septic Tank New • Existing
Cesspool � New Existing
Residential Non-Residential
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.)
AP 0/, 3 (7;4,1a
Ire.
Signatur- o Applicant
RECEIVED BY: _...,4,4410_,P,
own rle s Office
DATE:
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