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10 If Wirt.
JUDITH T. TERRY f Town Hall, 53095 Main Road
TOWN CLERK z' * < P.O. Box 1179
REGISTRAR OF VITAL STATISTICS sv Southold, New York 11971
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MARRIAGE OFFICER o- .> r � Fax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1708-R Residential X Non-Residential
Fee $ 10.00 . Septic Cesspool X
New Existing X
Name Of Owner YARO, OTTO AND ELIZABETH
Mailing Address 1 P. O. BOX 1221
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1895 MINNEHAHA BLVD.
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2279
Tax Map No. section 87.00 block 3 lot 61 .000
Cross Street WABUN STREET
Date Of Last Pump Out 0/00/86
Issue Date: 6/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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- OFFICE OF THE TOWN CLERK �S\FFU(,(r"'-
Town of Southold CQ - Application No. Ile&
Judith T. Terry, Town Clerk % ,,..• : 4 . �►
� 7` ,� - %4 $10.00 — Residential
Town Hall, 53095 Main Road y
P. O. Box 1179 u' " i f - ' ,' $25.00 - Non-Residential
Southold, New York 11971 O O 4'4*---. .� - -$
Telephone ,( ..
(516) 765-1801
TOWN OF SOUTHOLD
' SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. _
Fee $
DATE 3-0/4(7-- (S` ( q R1 -
OWNER NAME: (9T- '' L-c 2ftr t� bA- --'frcf2 0
OWNER MAILING ADDRESS: e0 . 12_24
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OWNER PROPERTY ADDRESS: )gc!-S- M_l hJr i6-tc, - FP4 - az--Jz9,
.-co 0 1-1-1,6-yip
OWNER TELEPHONE NUMBER: 76 S- --2---2-75
TAX MAP NO. : Section F 7 Block 3 Lot 7
CROSS STREET: (oil fl-vIs S7-`,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing x
Residential ' y Non-Residential
DATE OF PREVIOUS PUMP-OUT: Sra1 NA Sb
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.)
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Signature of Applic t
RECEIVED BY: s( e.-)
(a/ Town Clerk's Office
DATE: & /( .. /T(/
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