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JUDITH T. FERRY . Town Hall, 53095 Main Road
P.O. Box 1179
TOWy'CLERK
REGISTRAR OF VITAL STATISTICS C Southold, New York 11971
MARRIAGE OFFICER ® �i� Fax (516) 765-1823
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,D 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. 1878-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner AUSTIN, ELBERT V.
Mailing Address 1 RT 2 - 470 HARBOR LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 470 HARBOR LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7357
Tax Map No. section 97 block 6 lot 6
Cross Street ROUTE 25
Date Of Last Pump Out 0/05/91
•
Issue Date: 4/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/ see
O FLCE OF THE TOWN CLERK cFD(I �'
Town of Southold �� Q � Application No./
Judith T. Terry, Town Clerk ��,y .
r. x .G .
Town Hall, 53095 Main Road � 7 $1000 - Residential
� /$
Fr O. Box 1179 cnf. ` $25.00 - Non-Residential
Southold, New York 11971 �y� �0���`
Telephone ,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. J ? )
Fee $ 7,6 , co
DATE y/`/ /
OWNER NAME: c1- D c'2 7- V. 7ft, S 71--/A/
OWNER MAILING ADDRESS: 0- 2 - '-/7o 179-5/30
LL0- c a o e /V y 11 93y^
OWNER PROPERTY ADDRESS: .5.,¢ : e 1-5 7/8 a ✓'
OWNER TELEPHONE NUMBER: 3-74 - ”L/ - 7 3 5 7
TAX MAP NO. : Section Block Co Lot ,
CROSS STREET: R
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: /1--}/ of , F9')
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.)
Signature of Applicant
RECEIVED BY: , W -
own Clerk's Office
DATE: /3
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