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JUDITH T. TERRY ., Town Hall, 53095 Main Road
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TOWN CLERK 6 ti P.O. Box 1179
REGISTRAR OF VITAL STATISTICS rgrb Southold, New York 11971
MARRIAGE OFFICER ® �r' Fax (516) 765-1823
®�4! Telephone (516) 765-1801
rcli *4OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1857-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WILLIAMS, MRS. HADLEY B.
Mailing Address 1 (MRS. B. WHEATLEY WILLIAMS)
Mailing Address 2 13606 ALEPPO DRIVE
City St Zip SUN CITY WEST NY 85375-0000
Property Address 1 10725 NEW SUFFOLK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 602-546-0146
Tax Map No. section 116.00 block 1 lot 5.000
Cross Street MOORE'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/20/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �cj1FUL4-CQG'`
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Town of Southold �� .•, .. ,, Application No.
Judith T. Terry, Town Clerk Ee
Town Hall, 53095 Main Road $10.00 - Residential
a
p. O. Box 1179 r;=; H z` $25.00 - Non-Residential
Southold, New York 11971 •te "
Telephone -.7e11;& �� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ � •
DATE hm-,2_
OWNER NAME: A1s. LE-7
B_ 11, I Li-IA S ,es. .1U/464r-67iflzi 1- us
OWNER MAILING ADDRESS: /3464 ASG--i po 2Ifl1
SiJCrryI.z1�� 2, 3
OWNER PROPERTY ADDRESS: /b 7 6 (J,C/=dLk /Iva
Curt(1--z5G-u6 N.1 /193s
OWNER TELEPHONE NUMBER: (/ga y qq 0 /4/6 &z )
TAX MAP NO. : Section / f ) Block ( Lot ,ST
CROSS STREET: �y ��l�l Li r'� e�a� �bZo Id. 'Ai 0611,E'Sa II-,11T
TYPE OF SYSTEM: Septic Tank New Existing
VCesspools New Existing
Residential >c Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ap/Lees„,e); i,; — 0.2% J 2,44 . 2
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.)
01: I , /
Signature of Applicant
,,er �, /JILL/4/244
RECEIVED BY:
Town CI rk's Off'ce - RECEIVED. -
DATE: MAR 2 0 1gc°
Town Clerk Southold
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