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Town Hall, 53095 Main Road
;_1st— P.O. Box 1179
® ;,r Southold, New York 11971
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JUDITH T.TERRY --'1..~.:,,,,,°.
TOWN CLERK (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. 631-R Residential X Non-Residential
Fee $ 10. 00 Septic X Cesspool
New Existing X
Name Of Owner CHARLES G. BURCK
Mailing Address 1 41 GLEN BYRON AVENUE
Mailing Address 2
City St Zip SOUTH NYACK NY 10960-0000
Property Address 1 1700 VILLAGE LANE
Property Address 2
City St Zip ORIENT NY, 11957-0000
Owner Telephone No. 914-353-3423
Tax Map No. section 24 block 2 lot 17
Cross Street FLETCHER STREET
Date Of Last Pump Out 0/00/00
/5/
Issue Date: 3/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK \\FFA
Town of Southold "AO.
Application No.6Judith T. Terry, Town Clerkt ,„,94.1,%,
Town Hall, 53095 Main Road 'y* �?} 7 Residential
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P. O. Box 1179 . i , Non-Residential
Southold, New York 11971 '�®: 'r} ,
Telephone -_e? ' +
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATIONPERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ iI
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OWNER NAME: eim„,,,,,, , ,T3U,z'U,.._,
OWNER MAILING ADDRESS: Y--1 ( /(;A) 1311110/j hif6�
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OWNER PROPERTY ADDRESS : /1 op au,1,/3C,Li ii�vvb-
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OWNER TELEPHONE NUMBER: 0, 19, `;� ' -D-3
TAX MAP NO. . Section Block Lot
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TYPE OF SYSTEM: Septic Tank X New Existing x
Cesspool New Existing
Residential 5e Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3004/1911 1917
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
f� of distance, approximately, to building and closest road.)
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iiiiiw"i•na`'ur of 'Applicant
RECEIVED BY:
Town Clerk's Office
DATE: