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JUDITH T. TERRY -xl Town Hall, 53095 Main Road
TOWNHall,‘kZ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ® '� _ f; Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
`, Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1709-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CROWLEY, JOSEPH A. AND ROSE M.
Mailing Address 1 RR1, 1005 MASON DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1005 MASON DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5891
Tax Map No. section 104.00 block 5 lot 36.000
Cross Street HAYWATER DRIVE
Date Of Last Pump Out 0/00/81
Issue Date: 6/19/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C��FFd(�••'•.
Town of Southold �� - CQ ' , Application No. //77/�
Judith T. Terry, Town Clerk �
Town Hall, 53095 Main Road ``` $10.00 - Residential
p. O. Box 1179 k; �'` hi $25.00 - Non-Residential
Southold, New York 11971O�o _- ��0�
Telephone `!
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /p
DATE -Sol -C 19 % 1
- OWNER NAME: J o 5 G P l-I .n C2_,0 r F
OWNER MAILING ADDRESS: {2 R- I to c' 5 6`"1 /k�o rJ
VI-0 c- r' 1 ' ' '2 r
OWNER PROPERTY ADDRESS: Prr 1 L
OWNER TELEPHONE NUMBER: "l '7 4- S 8-1J
TAX MAP NO. : Section t D Block S Lot 3
CROSS STREET: 14-pc-yl/k.)- -,-;--re- 09,1 urr.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 74: New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: c4t S I 'fro
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.)
(6-"K_A.,)
Sigrutture of Applicant
RECEIVED BY: .cam Clerk's wv.� z wIer
n k's O fice
DATE: JUN 1 9 19?1
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