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JUDITH T.TERRY �I1 #
d Town Hall, 53095 Main Road
TOWN CLERK
P.O. Box 1179
s1.44,;*. �9 1
<;, Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �� ter'
MARRIAGE OFFICER w� '44 jolts. ®�11� Fax(516) 765-1823
Q1 1 Telephone 516
RECORDS MANAGEMENT OFFICER :_1 �3 � �1 p ( ) 765-1800
FREEDOM OF INFORMATION OFFICER . '1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3696-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VAN BUREN, EDGAR AND DONYA
Mailing Address 1 P. O. BOX 162
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 6955 BAY AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7812
Tax Map No. section 104.00 block 4 lot 33.022
Cross Street HAYWATERS ROAD
Issue Date: 10/07/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK /COMA'
Town of Southold oCQG Application No.S69'
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road {. ;v .,. !c I $10.00 - Residential
P. O. Box 11794..;• $25.00 - Non-Residential
Southold, New York 11971 O ""
Telephone ( * y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /e), bo
DATE /V /
OWNER NAME: / C! e2 q A24/74--
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OWNER MAILING ADDRESS: ,/ 7 0j< /C,Z/
OWNER PROPERTY ADDRESS: '6; 4� ��'e -
cic/� Zm, .f /YY /// 3s--
OWNER TELEPHONE NUMBER: (...5—/6- — 7 3.Y-
TAX
Y-
TAX MAP NO. : Section /6.7 r-00 Block ®Y- .00 Lot .!:7.3 3. oa f
CROSS STREET: /V__.6 AJ TJ
f
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 1 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.)
Signature of Applicant
RECEIVED BY: ALAZGLA-z--c.-(42
Town Clerk'3�Office
DATE: /U/Cp , k7
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