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Town Hall, 53095 Main Road
3 ~ �' P.O. Box 1179
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JUDITH T.TERRY =-_®j � of TELEPHONE
MIVN 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. 782-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner CHARNEWS, DANIEL AND WIFE
Mailing Address 1 BOX 573
Mailing Address 2 YOUNGS AVENUE
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3741
Tax Map No. section 63 . 00 block 1 lot 25. 000
Cross Street COUNTY ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 8/10/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK
Town of Southold 4\ i-OLA
�% Application No. -7a
Judith T. Terry, Town Clerk gi4r y
Town Hall, 53095 Main Road a a. «- rs 1 Residential
P. O. Box 1179 to Non-Residential
Southold, New York 11971 `P"
Telephone _0
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 7v-)___
Fee $ /O
DATE
OWNER NAME: 'DAN e bV p C'.ttA ee
OWNER MAILING ADDRESS: Aak-$13 yaivne-c AUS SOCC-1-401.--D 1 ( 77/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: —7/s-3'74/
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TAX MAP NO. : Section 6 3 Block / Lot
CROSS STREET: F
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signa ure of Applicant
RECEIVED BY: 6e_ cle,
�' fira � down C rk's Of ice
DATE: AN 1 0 Vtg. ;
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