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JUDITH T.TERRY ►/_ Town Hall, 53095 Main Road
TOWN CLERK ; _ P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �`®� ��� Fax(516) 765-1823
MARRIAGE OFFICER = 4j® 40* o Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER : .°? �
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. 3397-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VON SEELEN, RICHARD & CAROLYN
Mailing Address 1 3495 HAYWATERS ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 3495 HAYWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-4191
Tax Map No. section 111 .00 block 11 lot 21 .000
Cross Street LITTLE PECONIC BAY ROAD
Issue Date: 10/20/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE., OF�THE TOWN CLERK ' . FQ _ 7
Town of Southold ����, e&,` Application No. 3 3
Judith T. Terry, Town Clerk ��
Town Hall, 53095 Main Road $10.00 - Residential '
P. O. Box 1179 cr., ' M `1 $25.00 - Non-Residential
Southold, New York 11971 O ' o*-$
Telephone *O.y * $� .�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT .__' `
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 —
DAT E®4--- /® /M----
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OWNER NAME: (46.174gfrP '' r � ��al
OWNER MAILING ADDRESS: ,) ,r /`,
ni .,/ahLL�f /Ce' 3 .---
OWNER PROPERTY ADDRESS: /;260
OWNER TELEPHONE NUMBER: ,_<;/-t‘ ----.7 „K.-0,v
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TAX MAP NO. : Section Me 0 C) Block - 0 0 Lot oQ a .0(96
CROSS STREET:
TYPE OF SYSTEM: Septic Tank , ' New Existing
Cesspool New Existing
V1
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.)
I
Signature of Applicant
RECEIVED BY:
t � '' ` ' -1To '= � s Office
DATE: OCT 1 :” 1995
Town Cie& Souttiola
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- NOTE -- . • 'A i� OF ..`;/• •Ti:3_.E,. !,,:.%,
Lot numbers shown refer t_. " Map of GuaranYCtd to the 5ecuri+ Tri-it. a::d Gurir-mf j
Secfton D - Nassau Pc::.t .::Lti Prcp_ ., :.ccn.pany and -to the $outho{d 5t ii :-,c3s i:c_1...
inc." on foie to 'tri: SuftV.,. Oc.n.f^3 Cierkr, 5urvused .. .May ;tti , f967
Office as map number bob VAN TUYL & SOH
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rJeAL E = LiCe:nseG Land 5urve jorz.
o = Iron pi e Greeriport ,New York