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JUDITH T.TERRY t'� 4 x � Town Hall, 53095 Main Road
TOWN CLERK '� t = `� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 1� Southold,New York 11971
MARRIAGE OFFICER
� Fax' ®� � Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER � ���d� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER IF
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3744-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CROSS, CONSTANCE
Mailing Address 1 P. O. BOX 730
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 21833 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6874
Tax Map No. section 108.00 block 3 lot 8.003
Cross Street
Issue Date: 12/15/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ' \FFO
Town of Southold , ��� CQ Application No.3 7
Judith T. Terry, Town Clerk Z . VAl
Town Hall, 53095 Main Road' $10.00 - Residential
P. O. Box 1179 CA
$25.00 - Non-Residential
Southold, New York 11971 O s�`
Telephone .0.( ift 1+ , '
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (b•0-0
DATE ia--I I�-I
OWNER NAME: C_G Ose-k0 C-C- "SS
OWNER MAILING ADDRESS: (9.0 . g -13D
N` 11613-s--
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: sib - -134— (.0 .-14.. cam.. (A-39
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic'Tank New Existing
Cesspool New Existing X
Residential Non-Residential
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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.)
•
ri9jniCj
Signature of Applicant
RECEIVED BY:
, Town Clerk's Office
DATE:
- -- --
TOWN OF SOUTHOLD
1�,,�.,5�FFOureo
M A c Ticket No. ' 14281 '
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....-...
° °SCAVENGER TE REPORTO �
Name of Haul ref !
1 � ull Load @ .. l/`v "
�� Gallons
Permit No. ., 0 Half Load Gallons
Truck Capacity ... X1'7-1,1 0 $ Paid
(date)
LOCATION/
Split load @ Gallons
❑ \ Repeat (validation of Payment)
Name of sStreet-.. ...
„ ,
Hamlet '
may. ..
Telephone No0.44.—. ..-44... Tax Map No. f.. .. ,.,
j ../....3...
Cross Street' '�'
I G
DIAGRAM (Locate buildings and cesspool/septic system and approximate distance in feet ' i
between buildings and system; give north arrow.)
, .? . 1 •
I
I hereby certify that the above originated within the Town of Southold/Town of Shelter Island
at the above location, and to the best of my knowledge contains no chemicals, hazardous, or
toxic wastes. False statements made herein are punishable as a misdemeanor pursuant to
Section 210-45 of the Penal Law of the State of New Y6{r c,'and may result in my arrest and the
impoundment of the vehicle I am .,.ring.
Name of Driver { /
Signature of Driver....-
6
Received by .... JO 4 Ail. ,
Date (it7 7 Time
(i) ';t;rqm,:;:it Plant