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OFFICE OF THE TOWN CLERK Ofe `,�
Town of Southold
Judith T. Terry,' Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971 O
Telephone of -sr
(516) 765-1801 _% -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 116 Residential X
Non-Residential
Fee $ 10.00 Septic X Cesspool X
NAME OF OWNER: Peter and Susan Young
OWNER MAILING ADDRESS: 1270 Cedar Drive
Southold, New York 11971
OWNER PROPERTY ADDRESS: 1270 Cedar Drive
Southald, New York
OWNER TELEPHONE NUMBER: 516-765-1590
TAX MAP NO. : Section 78 Block 8 Lot 19
CROSS STREET: North Bayview
TYPE OF SYSTEM: Septic Tank X New Existing x
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: June 1986
efX04;e011.0070•00,
Judith T. Terry
Southold Town Clerk
•
DATE: October 30, 1986
(TOWN SEAL) -
OFFICE OF THE TOWN CLERK cI\FFpC,+�
Town of Southold Application No. //�
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road } �: : Residential
P. O. Box 1179 cr3k '630 ;' �� Non-Residential
Southold, New York 11971 O " �x •W$
Telephone
Telephone/ NX6'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. //6,
Fee $ //), DZ)
DATE Oct. 2-, /5a 6
OWNER NAME: Pe-0 5U,S -- �C U,(J i�-
OWNER MAILING ADDRESS: /L
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: - /.r-96-.)
TAX MAP NO. : Section Block S Lot /
CROSS STREET: ""2/0-7,4;74-' , yi0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature of App cant
RECEIVED BY: 4t�
Town erk's ffice
DATE:
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