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JUDITH T.TERRY � :gfc.4 Town Hall, 53095 Main Road
TOWN CLERK _ ; P.O. Box 1179
Southold,!:4441 PPY New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER L�� F yet Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ®1 45 1d*���� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,•01
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3729-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BAKER, LOUIS AND OTHERS
Mailing Address 1 P. O. BOX 112
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTOHLD NY 11971-0000
Owner Telephone No. 516-765-5700
Tax Map No. section 70.00 block 2 lot 12.000
Cross Street JOCKEY CREEK DRIVE
Issue Date: 11/24/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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Ofi FIcE OF THE TOWN CLERK �FFO
Town of Southold , Q� �C'D�t Application No.57 02.9
Judith T. Terry, Town Clerk
erk .,..,
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cna •;, •`"-;: . ;' $25.00 — Non-Residential
Southold, New York 11971 O- $!``'`'' ` �••$
Telephone 1 1 y1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION ,PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
• DATE
r
OWNER NAME: 1.1--C�v C-1S S \C - C_. ` i CY\\`\\YC_
OWNER MAILING ADDRESS: N,\J ( C7 1 )�
OWNER PROPERTY ADDRESS: ��(� j -g
OWNER TELEPHONE NUMBER: •,�` � -)U l�
j TAX MAP NO. : Section Gr. Block oZ. Lot / t_____
CROSS STREET: 0 LW,_ \ � \C�F\�L
TYPE OF SYSTEM: Septic Tank -\\,77- New Existing . \\.(7.2.—
P
Cess oolNew Existing
Residential \/ 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.)
"-(--cep 79,,,g,....4.-_—__—
Sign ure of Applicant
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RECEIVED BY: /Vi /
/6t---`2--z-LqTown Clerk's ffice
DATE: /7//is----/97
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