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�• Town Hall, 53095 Main Road
t -V ���.' P.O. Box 1179
it ,: •s Southold, New York 11971
JUDITH T.TERRY ' %�. r/- /'�`� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1463-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BUHLER, EDWARD CARLL
Mailing Address 1 BHULER, CAROLINE T.
Mailing Address 2 RR 1, 50 EASTWOOD DRIVE
City St Zip CUTCHOGUE NY 11935-0000 .
Property Address 1 50 EASTWOOD DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7555
Tax Map No. section 110.00 block 3 lot 16.000
Cross Street MIDWOOD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
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Town of Southold % ..,:- eQ" Application No./114‘.3;•,1
Judith T. Terry, Town Clerk • 4t `
$10.00 - Residential
Town Hall, 53095 Main Road
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P. 0. Box 1179 'l' •
� .� �;,;;', �•� $25.00 - Non-Residential
Southold, New York 11971 O :c_ ,
Telephone ( 4 A
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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 $
DATE .& ` ( `{/?U
OWNER NAME: /Alt/, G�R/� B-U**Go,e Aittp L,�Rai �,✓ � tvNai-<
OWNER MAILING ADDRESS: j R,�►/P`/ 42' g-4� 72700;46 .�
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OWNER PROPERTY ADDRESS: �W eoea,'f o=9-57-woo .- 47/p.4 410.. ? ?5
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OWNER TELEPHONE NUMBER: 73 �' �
TAX MAP NO. : Section //!J Block ;7 Lot 1/,
CROSS STREET: Mi-Olvvo0 gootD
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: �'/� �9r� r"��e�T /91, p avi/IV aseAR.S
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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 Applicant
RECEIVED BY: ei�„
Town Cle ' Q➢lf ' e
DATE: MAY 1 7 MN
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