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=$ Town Hall, 53095 Main Road
e % P.O. Box 1179
' _°4 j 0° Southold, New York 11971
JUDITH T.TERRY
'''''''' ,4,0- TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 707-R Residential X Non-Residential
Fee $ ' 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BAUNACH, KARL R.
Mailing Address 1 225 PINE STREET
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 225 PINE STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4124
Tax Map No. section 141. 00 block 1 lot 36.000
Cross Street HORTON AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE -TOWN CLERKc��FFD(,r
Town of Southold % ,:.. CApplication No. 207
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Judith T. Terry, Town Clerk ` ,�, f
.0 Residential
Town Hall, 53095 Main Road � ,g, �fi, .
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P. O. Box 1179 En �"= I _ hi ;' Non-Residential
Southold, New York 11971 OevAr,
Telephone _OI
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE J //6 /W
OWNER NAME: 69-2.,4. 7L R�� '
OWNER MAILING ADDRESS: a j.S i'A/ �r
OWNER PROPERTY ADDRESS: ,L1 p, IVE S
OWNER TELEPHONE NUMBER: 0 le — - Lit he 2-
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TAX MAP NO. : Section /CH Block ( LotIJ�� 3-
CROSS STREET: ®("LA) 1 /9V&.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,-/M `Pr
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.)
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Signature of Applicant
RECEIVED BY: 0 a- �. ,�.,:p )
Town XIerk 's t�'ffice
RECEIVED
DATE:
MAY F? 1988
Town Clerk Southold
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