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JUDITH T. TERRY $ ` Town Hall, 53095 Main Road
TOWN CLERK ac P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T ' Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765 1823
®��® : AAV Telephone (516) 765-1801
1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1663-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BAXTER, ERNEST
Mailing Address 1 P. O. BOX 627
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 8400 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2105
Tax Map No. section 31 .00 block 8 lot 3.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE Of THE •TOWN CLERK •S��FO(,r��''•
Town of Southold % \_ ._ CO Application No. / 6 3
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 cn ' . sr` a
-•eZ $25.00 - Non-Residential
Southold, New York 11971 O _
Telephone *0j 101
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
10 r
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / .3
Fee $
DATE •a4z.)..k
OWNER NAME: GGA\ -ea`S z)
OWNER MAILING ADDRESS: ?a —60� to-271- c6L'40 0 MF�iN}
6'YV 'o � xL") 3 `7
OWNER PROPERTY ADDRESS : -.c -we.e
OWNER TELEPHONE NUMBER: dt,11-21.0
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank ' New Existing
Cesspool New Existing
Residential DC., Non-Residential
DATE OF PREVIOUS PUMP-OUT: \Jo -CAR-0.; — 1I ►n,. LA 10 a_
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 A plicant
RECEIVED BY: / '/
• n I erk s 0 ice
DATE: ,.4//e72-//4iy