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JUDITH T.TERRY N 'A Town Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
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-1� � � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1
MARRIAGE OFFICER � �� -rg. Fax(516)765-1823
l Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER ; • ll
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FREEDOM OF INFORMATION OFFICER - •��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3319-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BAKER, CATHERINE A.
Mailing Address 1 P. O. BOX 603
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2545 HAYWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5202
Tax Map No. section 111 .00 block 7 lot 9.000
Cross Street HARRINGTON ROAD
Issue Date: 4/24/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�VFFULA- -
Town of Southold , Oho CQG', Application No. /r
Judith T. Terry, Town Clerk y:\
Town Hall, 53095 Main Road -� ! $10.00 - Residential
P. 0. Box 1179 cn - == `' $25.00 - Non-Residential
Southold, New York 11971 Q '`° �����
Telephone Q( l �%�;��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /4,
DATE 11,410e
OWNER NAME: RICA 6,
OWNER MAILING ADDRESS: Aix, tg bgill
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OWNER PROPERTY ADDRESS : (95.116 ,970p7-0, eitl oad,
(�gi, 'e-b�s �,�' m�J 4ah>a16 h-1s //
OWNER TELEPHONE NUMBER: 'cig )84- j -a5 •
TAX MAP NO. : Section /1/ Block 7 Lot 17
CROSS STREET: // /wc[60, iej I
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential G,/ Non-Residential
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: Cy ()_19oc_-)
Town Clerk's Office
DATE: o2i ji/lir
11 PPS
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