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JUDITH T.TERRY /11ec Town Hall, 53095 Main Road
TOWN CLERK ` c P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
V6 471 Southold,New York 11971
MARRIAGE OFFICER �°i4, 0- Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER : ®,1 `�►`:11 Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3511.1-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CARRUTHERS, ROBERT
Mailing Address 1 P. O. BOX 847
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 12600 NEW SUFFOLK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6136
Tax Map No. section 116.00 block 6 lot 13.000
Cross Street BAY ROAD
Issue Date: 11/13/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
a
OFFICE OF THE TOWN CLERK '5§fF0(r��-
Town of Southoldoho
Ql/ Application No.3 ;�Y/
Judith T. Terry, Town Clerk �� t., y
Town Hall, 53095VVIain Road $10.00 - Residential
P. 0. Box•-1179 cal 'f i �' $25.00 - Non-Residential
Southold, New4York 11971 %°,11:;)*
Telephone �( 411
(516) 765-1801 „
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE //lh,li‘
OWNER NAME: � 01 16,. 4A--l}
OWNER MAILING ADDRESS: /3 s- 'y L/ 7
64_7-- l //y z
OWNER PROPERTY ADDRESS : /•Z, 46 b ,�/E X/ rt,,A 6L 14-16-A-44„.
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OWNER TELEPHONE NUMBER: 574 - 73(74- e'/�
TAX MAP NO. : Section Block Lot / 3
CROSS STREET: b f po$ 1`1t /54-1_/ 6-)/4-?)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r/ New Existing
Residential / Non-Residential
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.)
724)
Signature of Applicant
RECEIVED BY:
own Clerk's ffice
DATE: // / / q �
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