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OFFICE OF THE TOWN CLERK tf OUr`D
Town of Southold ` -:,fr lj
Judith T. Terry, Town Clerk }
Town Hall, 53095 Main Road 0
P. 0. Box 1179 ,; e 0 i ,
Southold, New York 11971 •��
Telephone =g( 44,
1 b •'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 168 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Helene B. Young
OWNER MAILING ADDRESS: 735 Ruch Lane
Southold, New York 11971
OWNER PROPERTY ADDRESS: 735 Ruch Lane
Southold, New YOrk
OWNER TELEPHONE NUMBER: 516-765-1527
TAX MAP NO. : Section 52 Block 3 Lot 6
CROSS STREET: Route 148
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: October 1983
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44;14$9
Judith T. Terry
Southold Town Clerk
DATE: December 8, 1986
.
(TOWN EAL)
OFFICE OF THE TOWN CLERK � FD(1.-'-
Town of Southold % Ce % Application No. %6,f
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road � �" ;,, _ -
r Residential
u
P. O. Box 1179 34 :' Non-Residential
Southold, New York 11971 �`..; = ����`
Telephone i sttv,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /6
Fee $
DATE A-e_S /7RE
OWNER NAME: F1ELELvE I7 . (] (./
OWNER MAILING ADDRESS: 1., ._e-act-64-V
OWNER PROPERTY ADDRESS: 735uci-/ LANI
So (/7-6' DL DDI 4,/.y, 1 (�7
OWNER TELEPHONE NUMBER: 776s /f27
X2,13 SW1S H-173 `1
TAX MAP NOV;-: Section / Block Lot 1)
CROSS STREET: �c,c. (41.g-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New _ Existing
Residential Com, Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6 - /% C /���
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.)
/aa /3 . a,e,,,,AcvSignature f Appli
RECEIVED BY: " �-��
Town Qrk's Of ice
DATE: REC�8��® llllll//////
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