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t Town Hall, 53095 Main Road
11 oi, �� P.O. Box 1179
__,�l®1 sit � ��0 Southold, New York 11971
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JUDITH T.TERRY
--,,,,,,,,,,,0°• FAX FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1379-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X •
New Existing X
Name Of Owner BAYLEY, ROBERT
Mailing Address 1 P. O. BOX 595
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 150 LAKEVIEW TERRACE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-5024
Tax Map No. section 31 .00 block 9 lot 18.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
"� '_i • iii
OFFICE OF THE TOWN CLERK i
Town of Southold C� Application No. 1377
Judith T. Terry, Town Clerk - ';
Town Hall, 53095 Main Road �
"'� ' , -,, �G $10.00 Residential
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P. O. Box 1179 un4� • ^moi ,
® F;1".' $25.60 - Non-Residential
Southold, New York 11971 0
Telephone
4'j * 1‘��
(516) 765-1801
TOWN QF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. - --
Fee $ [Of 00.
DATE ,E 5 ' "0
OWNER NAME: Ro &i �.�i(-j
OWNER MAILING ADDRES :J) .01 Dox CJGI Jr'
�A�T MA 711 K 1\1 , Y► d t 9 51 -
OWNER PROPERTY ADDRESS:` I, 50 L MR/A-G_
r t MA- (01 ) 1\(i `t;
OWNER TELEPHONE NUMBER: tj ( & -1-77 502-1-
,
TAX MAP NO. : Section SI , 00 Block Lot ( 8, 000
CROSS STREET: 154, AuEL\LUE.
TYPE OF SYSTEM: Septic Tank '00 ALNew ✓ Existing
Cesspool 1.. AIY6 New \./• Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: F�t3 Z ) 1960
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.)
xic
Signature of Appli %nt
RECEIVED BY:
Own Clerk's Office
DATE:
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