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JUDITH T. TERRY : ` Town Hall, 53095 Main Road
TOWN CLERK p
FT : P.O. Box 1179
to ,' Southold, New York 11971
REGISTRAR OF VITAL STATISTICS `✓o �� Fax (516) 765-1823
MARRIAGE OFFICER
*9 .1' Telephone (516) 765-1801
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. 3207-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WILLS, J. G.
Mailing Address 1 18-15 BAYSHORE ROAD
Mailing Address 2
City St Zip GREENPORT JY 11944-0000
Property Address 1 18-15 BAYSHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1933
Tax Map No. section 53.00 block 4 lot 8.000
Cross Street BAYVIEW AVENUE
Issue Date: 5/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
iii •
OFFICE OF THE TOWN CLERK c��FFaure,-
Town of Southold �Q COG; Application No. i c1-O
Judith T. Terry, Town "Clerk' ''';..r.'srM,....';_-„ y
.G $10.00 - Residential
Town Hall, 53095 Main Road4'�[ • -
P. O. Box 1179 IOW �• $25.00 - Non-Residential •
Southold, New York 11971 p ® Off•- �
Telephone "e?"44(...
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /6
a
DATE 17,
177.
OWNER NAME: J ( , 77
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OWNER MAIL NG ADDRESS: /3 7.K--
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OWNER PROPERTY ADDRESS: /]G
OWNER TELEPHONE NUMBER: ,S7 ((2 G/, /9.3=7-
TAX MAP NO. : Section S3 Block ! Lot g
CROSS STREET: J LCgr /1 //'e--'
• TYPE OF SYSTEM: Septic Tank �� New Existing (-.
Cesspool New Existing
Residential C/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6-77- 9(�/
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.)
•
/ V , i/,
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ii
mimpif ..�fA” of Applicant
RECEIVED .BY: kr ��11 cam
Town Cle�ik's Office
DATE: 7 )/ 2K-
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