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JUDITH T. TERRY •• Z L Town Hall, 53095 Main Road
TOWN CLERK T P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS Tri
Southold, New York 11971
MARRIAGE OFFICER ma ® Nr. Fax (516) 765-1823
_-°�, ul .. Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2094-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ASHDOWN, CHARLES E. JR.
Mailing Address 1 9635 PERCUSSIAN WAY
Mailing Address 2
City St Zip VIENNA VA 22182-0000
Property Address 1 1315 WATERSEDGE WAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 703-938-0714
Tax Map No. section 88.00 block 5 lot 67.000
Cross Street GIN LANE
Date Of Last Pump Out 0/00/70
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
fi
•; 9FFICE OF THE TOWN CLERK c31FOUr
Town of Southold0�� 3,. CQG• , Application No. c:WC:3//--
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road _ ' $ 07601 Residentialli ft.,
P. O. Box 1179 cna ` $25.00 - Non-Residential
Southold, New York 11971 Off; . 0��%,
Telephone �l * Y►�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ lQ• — 3"--hah3 DATE
OWNER NAME: CA 440444I s Liv rY rT1,,
I
OWNER MAILING ADDRESS: 9635- Pe. C1/43Ss'-av I- (A/A-4
--OWNER PROPERTY ADDRESS: - -- �'IF�.vs,e .\6461,1- O 1_ y
� fly ) 1T-7/7/ U
OWNER TELEPHONE NUMBER: t7b3) cin-- 61)11-
g
n- 61)Ll-
r'' TAX MAP NO. : Section Block .s Lot (6,-7
CROSS STREET: evio..5 ' /�-�tw� � 0012,- `r5e_A rUd4;yV�
TYPE OF. SYSTEMc' Septic Tank New :;- Existing 7\
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:- 4.- N11O ? � E� � �s hPeenl vel
L
Mo 5a {-rM
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.) Ati,e,.P16
C-1)-^/vt-Qt4._ k-c,L•rv ,
Signature of,pplicant
RECEIVED BY: ,,
Town CI rk's Office - -
- - , - --
DATE:- 9 -
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