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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK • pT • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS urs � Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
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®� l� o- 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. 3083-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VAN WYCK, HENRY F.
Mailing Address 1 34 SUNSET ALNE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 34 SUNSET LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1460
Tax Map No. section 33.00 block 4 lot 68.000
Cross Street SUTTON PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 8/10/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COW
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Town of Southold �� _, e, Application Application No. 3
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Judith T. Terry, Town Clerk . > ' _ y
Town Hall, 53095 Main Road �.
.•G 1 $10.00 - Residential
P. O. Box 1179 u' '� : $25.00 - Non-Residential
Southold, New York 11971 Oho
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Telephone ( i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ lv
DATE •3
OWNER NAME: A,
I
OWNER MAILING ADDRESS: 37 J lG //,s- 7 /, 4Y _
,6? A)00, Al 7/
b*NE'R PROPERTY ADDRESS,: 59j2
OWNER TELEPHONE NUMBER: r77f/�e/G
TAX MAP NO. : SectionW3a Block Lot
CROSS STREET: 'f/o i) /'
TYPE.OF SYSTEM: S- • is Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ail,
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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.)
Signa re of Applicant
RECEIVED_BY:
Town Clerk's Office
DATE: