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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK t T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS cr) .' Southold, New York 11971
MARRIAGE OFFICER ,
�tFax (516) 765-1823
�1D�I6. 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. 3007-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROWN, ROBERT W.
Mailing Address 1 P. O. BOX 367
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 325 HORTONS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1082
Tax Map No. section 63.00 block 5 lot 17.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 4/27/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �SWFO(,t, =
Town of Southold , % r r. CQG Application No. Q e1
Judith T. Terry, Town Clerk .'YY '4" -_ y
_� •4 ‘' $10.00 - Residential
Town Hall, 53095 Main Road a r.7 . :�
P. O. Box 1179 cn i-M' = h�i �` $25.00 - Non-Residential
Southold, New York 11971 O�® {�A ' •6
Telephone
pyo . ,�o�-1,
Telephone ( 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
-
-for -- ---- _ -- - --
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -' 400'-,
Fee $ /0
DATE -3/1/7/ 3
OWNER NAME: Ja6C ;ct-' (t) (3ifiziAviA)
OWNER MAILING ADDRESS: 136 7( 3d?
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OWNER--PROPERTY ADDRESS-: --- 2-S //WO—el/U.5 1
X700-I O4,0 > /17)
OWNER TELEPHONE NUMBER: 2(5". /61�C__ i
TAX MAP NO. : Section Block Q 5- Lot / 7
CROSS STREET: 4/440 - eD
TYPE OF SYSTEM:- Septic Tank - New Existing
Cesspool 1 - New Existing Iri
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9' 3-5- •
LOCATION MAP: Must b attached hereto before permit may be issued.
(Locat building and system; give north arrow and feet
of dis ance, approximately, to building and closest road.)
It ,I 0 7 w/:,,y/a,,...___-
GSignature of Applicant
RECEIVED. BY: _. .AA ./L -- - - - -
Town Clerk's Of e
DATE: /1/ - - ``2 /
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