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JUDITH T. TERRY v It Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER tisso Fax (516) 765-1823
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��` Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1789-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BEARDSLEE, EUGENE B.
Mailing Address 1 85 FRUITLEDGE ROAD
Mailing Address 2
City St Zip BROOKVILLE NY 11545-0000
Property Address 1 BEACHWOOD ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-626-1084
Tax Map No. section 116.00 block 4 lot 24.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/89
Issue Date: 10/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'S�FFD(,-,,"
Town of Southold �% -r CQ - Application No. ` �?f
Judith T. Terry, Town Clerk �� A ..%Q
'• y �C 7 $10.00 - Residential
Town Hall, 53095 Main Road o o-��. ��, ��� .
P. O. Box 1179 4 ' �; $25.00 - Non-Residential
Southold, New York 11971 O�i�` "}�.�0 •��`
Telephone ,(
ie
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ !C'
DATE /0 - 3.-9/
•
OWNER NAME: kttG7 11/� 0 &;4,7Z .54--e.--77 -6---
OWNER MAILING ADDRESS: F ---- ie,ea./7"/,---.-oC�� ' 2
'a,Cc/7e. G A/y /7 e "---4e-LS--
OWNER
4OWNER PROPERTY ADDRESS: /0 ./. /-�ZGr,0',Z31
6.2a-TGA-a'67--c /1/->Z:
OWNER TELEPHONE NUMBER: -376 "0) g6--lo 824
j TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ( New Existing
Residential -✓ Non-Residential •
OF PREVIOUS PUMP-OUT: /9g• LOCATIONU I
P: Must be attached hereto before permit may be issued.
(Locate buildingandsystem; give north arrow and feet
Y �
._---a of distance, approximately, to building and closest road.)
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(:?' c 411/4, i
, 7/" id/L14_16(_,
-9- /2 Sinature of Applicant
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R ICED BY: •
Town Clerk's Office
DATE: '